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Full text of "CSAP Cultural Competence Series 3: The Challenge of Participatory Research: Preventing Alcohol-Related Problems in Ethnic Communities, Special Collaborative NIAAA/CSAP Monograph Based on an NIAAA Conference, May 18-19, 1992"

CSAP 



Compet 






The Challenge of 
Participatory Research: 

Preventing Alcohol-Related 

Problems in Ethnic 

Communities 

Special Collaborative NIAAA/CSAP Monograph 
Based on an NIAAA Conference, May 18-19, 1992 



SAMHSA 



. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Public Health Service 

Substance Abuse and Mental Health Services Administration 
Center for Substance Abuse Prevention 




t 



3 



Mtt*Sj^p2Xfo3 



CSAP Cultural Competence Series 3 



The Challenge of 
Participatory 
Research: Preventing 
Alcohol-Related 
Problems in Ethnic 
Communities 

Special Collaborative NIAAA/ 
CSAP Monograph 
Based on a NIAAA Conference 
May 18-19, 1992. ^^ 

Office of Minority Health 
Resource Center 

Editor: P0B0X37337 o ^„ 

Phyllis a. Langtoa Ph.D Washington, DC 20013-7337 

The George Washington University 
Sociology Department 
Washington, D.C. 

Managing Editor: 

Leonard G. Epstein, M.S.W. 

Division of Community Prevention and Training 

Center for Substance Abuse Prevention 

U.S. Department of Health and Human Services 

Series Editor: 

Mario A. Orlandi, Ph.D., M.P.H. 

Chief, Division of Health Promotion Research 

American Health Foundation 



The primary objective of the Center for Substance Abuse Preven- 
tion (CSAP) Cultural Competence Series is to promote the devel- 
opment and dissemination of a scientific knowledge base that 
assists prevention program evaluators, researchers, and prac- 
titioners in working with multicultural communities. 

CSAP supports the rigorous scientific analysis of programs 
designed to promote health and prevent alcohol, tobacco and 
other drug (ATOD) problems for all people. All positions taken 
on specific approaches to conducting research and evaluation 
on ATOD problem prevention programs are positions of the 
researchers, communities, prevention experts, and authors who 
contributed to this monograph and may not necessarily reflect 
the opinions, official policy, or position of CSAP; the Substance 
Abuse and Mental Health Services Administration; the Public 
Health Service; or the U.S. Department of Health and Human 
Services. Other groups that developed and /or implemented 
specific methods for researching or evaluating ATOD abuse pre- 
vention programs are documented in the text of this monograph. 

All material in this volume, except quoted passages from 
copyrighted sources, is in the public domain and may be used 
or reproduced without permission from CSAP or the authors. 
Citation of the source is appreciated. 



DHHS Publication No. (SMA)95-3042 
Printed 1995 

Project Officer: 

Leonard G. Epstein, M.S.W. 

CSAP Cultural Competence Series: 

Elaine M. Johnson, Ph.D., Director, CSAP 

Ruth Sanchez-Way, Ph.D, Director, Division of Community Pre- 
vention and Training, CSAP 

Robert W. Denniston, Director, Division of Public Education and 
Dissemination, CSAP 



Prologue 



With The Challenge of Participatory Research: Preventing Alcohol- 
Related Problems in Ethnic Communities, the Center for Substance 
Abuse Prevention (CSAP) continues its ground-breaking series 
of cultural competence publications. This volume in the Series 
represents a collaboration between CSAP and the National Insti- 
tute on Alcohol Abuse and Alcoholism (NIAAA). 

This compelling volume offers both theoretical and practical 
applications related to the field of alcohol prevention research 
and its responsiveness to the pressing concerns of this country's 
diverse ethnic and racial communities. Underlying each of the 
chapters is the premise that good behavioral science recognizes 
the importance of cultural competence as a significant factor in 
the quality of data collected. 

CSAP's Cultural Competence Series has as its primary goal 
the scientific advancement of evaluation methodology designed 
specifically for alcohol, tobacco, and other drug abuse (ATOD) 
problem prevention approaches within the multicultural context 
of United States community settings. The various multicultural 
communities which make up our country comprise a rich and 
diverse ethnic heritage. The Cultural Competence Series is dedi- 
cated to exploring and understanding this heritage and its criti- 
cally important role in the development of ATOD problem pre- 
vention programs. 

The Cultural Competence Series provides CSAP with a 
unique opportunity to formulate effective strategies that will 
have applicability for ATOD prevention professionals working 
in widely diverse settings. This unprecedented Series has estab- 
lished a framework for the transfer of innovative, cutting-edge 
technology in this area and a forum for the exchange of knowl- 
edge between program developers, implementors, and evalua- 
tors. It is the sincere hope of those who have contributed to this 
Series that it will stimulate new ideas and further prevention 
efforts among all Americans. 

Elaine M. Johnson, Ph.D., Director 
Center for Substance Abuse Prevention 



For Loran Archer 
Colleague, Researcher, former Administrator, NIAAA 



Foreword 



This volume is the third in a series of publications on cultural compe- 
tence sponsored by the Division of Community Prevention and Train- 
ing of the Center for Substance Abuse Prevention (CSAP). It includes 
the proceedings of a working group, "Alcohol Abuse Prevention 
Research in Ethnic Communities/' held in Washington, D.C., May 
18-19, 1992, sponsored by the National Institute on Alcohol Abuse 
and Alcoholism (NIAAA). NIAAA and CSAP share the mission of 
encouraging the advancement of knowledge in the prevention of alco- 
hol-related problems and have worked collaboratively toward this goal. 
For example, in 1990, a Request for Applications (RFA) was issued on 
"Community-Based Research on the Prevention of Alcohol-Related 
Problems" which resulted in the joint funding by NIAAA and CSAP 
of two community grants. This jointly produced monograph represents 
another form of collaboration between research and service agencies 
that facilitates communication between prevention researchers, service 
professionals, and others dedicated to prevention. 

Throughout the volume, the concepts of participatory research, 
cultural competence, cultural sensitivity, and community provide the 
anchors for the discussion of the prevention of alcohol-related problems 
in ethnic /racial communities. An underlying premise of this volume 
is that prevention research must be based upon a clear understanding 
of the cultural factors that influence the processes of prevention 
research and the development of community prevention interventions. 
This understanding can be developed more effectively through collabo- 
ration between the community and researchers. 

A review of the state of the art of community alcohol prevention 
research shows that we have much to learn about effective interventions 
and protective mechanisms against alcohol-related problems in ethnic/ 
racial communities. It is likely that the state of the art will change little 
unless new alliances are built between academic researchers and the 
community, and unless these alliances encourage participation by both 
groups in the various stages of the research process. As is true for 
this CSAP Series as a whole, this volume is dedicated to furthering 
that effort. 



Phyllis A. Langton 
Leonard G. Epstein 



V 



Contents 



Foreword v 

Phyllis A. Langton and Leonard G. Epstein 

Preface xi 

Phyllis A. Langton 

Part I. Introduction and Overview 

CHAPTER 1 

Applying a Participatory Research Model to Alcohol 
Prevention Research in Ethnic Communities 1 

Phyllis A. Langton and Elsie G. Taylor 

Part II. Cultural Issues in Community-Based 
Prevention Research 

CHAPTER 2 

Conducting Culturally Competent Alcohol Prevention 
Research in Ethnic Communities 21 

M. Jean Gilbert 

CHAPTER 3 

Culturally Sensitive Alcohol Prevention Research in Ethnic 
Communities 43 

James R. Moran 

CHAPTER 4 

Discussion Paper: The Relevancy of Cultural Sensitivity in 
Alcohol Prevention Research in Ethnic /Racial 

Communities 57 

Robert G. Robinson 

Part III. Conceptual and Methodological Issues in 
Community-Based Prevention Research 

CHAPTER 5 

Alternative Models of Community Prevention Research in 

Ethnically and Culturally Diverse Communities 67 

Mary Ann Pentz 



Vll 



CHAPTER 6 

Ethnic Communities and Research: Building a 

New Alliance 105 

Fred Beauvais 

CHAPTER 7 

Methodological Issues in Conducting Alcohol Abuse 
Prevention Research in Ethnic Communities 129 

Steven P. Schinke and Kristin C. Cole 

CHAPTER 8 

Methods to Create and Sustain Cross-Cultural Prevention 
Research Partnerships: The NAPPASA Project's American 
Indian-Anglo American Example 149 

Jon Rolf 

Part IV. Alcohol Prevention Research in Ethnic/Racial 
Communities: Case Studies 

A. American Indians and Alaska Natives 

CHAPTER 9 

The Prevention of Alcohol and Other Drug Abuse 
Among American Indians: A Review and Analysis of the 

Literature 183 

Philip A. May 

CHAPTER 10 

Native American Community Alcohol Prevention 

Research 245 

Pamela J. Thurman 

CHAPTER 11 

Discussion Paper: American Indian Alcohol Prevention 
Research: A Community Advocate's Perspective 259 

Jerry D. Stubben 

B. Hispanics 

CHAPTER 12 

The Prevention of Alcohol-Related Problems Among 

United States Hispanics: A Review 279 

Raul Caetano 



Vlll 



CHAPTER 13 

Alcohol Abuse Prevention in the Hispanic Community 305 

Richard C. Cervantes and Isabel Garcia 

CHAPTER 14 

Discussion Paper: Issues in Hispanic Alcohol Prevention 

Research: Comments from a Clinical-Community 

Perspective 321 

Judith A. Arroyo 

C. African Americans and Black Americans 

CHAPTER 15 

Alcohol Abuse Prevention Research in African American 
Communities 343 

John M. Wallace, Jr. and Lawrence S. Brown, Jr. 

CHAPTER 16 

Alcohol Prevention Research in Black American 

Communities 367 

Patricia A. Seabrooks 

CHAPTER 17 

Discussion Paper: Comments on Alcohol Prevention 

Research in Black American Communities 381 

Janet L. Mitchell 

D. Asian Americans and Pacific Islanders 

CHAPTER 18 

Alcohol Abuse Prevention Research in Asian American 

and Pacific Islander Communities 389 

Kiyoko M. Vanish 

CHAPTER 19 

Asian and Pacific Island Community Alcohol 

Prevention Research 411 

Ford H. Kuramoto 

CHAPTER 20 

Discussion Paper: Issues in Alcohol Abuse Prevention 

Research in Asian American Communities: 

A Researcher /Community Perspective 429 

Davis Y. Ja 



IX 



Part V. Framing the Research Agenda 

CHAPTER 21 

Alcohol Prevention Research in Ethnic /Racial 

Communities: Framing the Research Agenda 439 

Jan M. Howard 



Preface 



This monograph resulted from a working group held in Wash- 
ington, D.C., in May 1992. One purpose of the working group 
was to bring together members of ethnic /racial communities 
and research scientists to facilitate collaboration between the 
two groups. The four ethnic /racial communities included: (1) 
American Indians and Alaska Natives, (2) Hispanics, (3) African 
Americans and Black Americans, and (4) Asian Americans and 
Pacific Islanders. 

A main interest of the working group was to learn how 
ethnic /racial communities view alcohol use and abuse in their 
communities. We argue that research scientists need to include 
members of the ethnic /racial communities in various stages of 
the research process. The prevention of alcohol-related problems 
in ethnic /racial communities can be enhanced by inviting the 
community to participate in shaping the research agenda. 

Other issues addressed during the working group were: (1) 
the need to develop greater sensitivity among researchers to the 
special prevention needs of ethnic /racial communities, (2) the 
means to develop trust between research scientists and ethnic/ 
racial communities so that collaboration can occur, and (3) the 
process for converting research findings into useable tools for 
these ethnic /racial communities. The dialogue that developed 
during the working group was at times conflictual, spirited, and 
informative, and was productive. 

Many people contributed to the successful outcome of the 
working group and the production of this monograph. The most 
important are the attendees at the working group and the authors 
of these papers. Nancy Colladay arranged the facilities and 
resources necessary for a successful working group. Elsie G. 
Taylor and I served as co-project officers for this project during 
my Intergovernmental Personnel Act (IPA) appointment at 
NIAAA during 1991-1992. We also co-authored the introductory 
paper. Amy Shapiro, Branch Secretary, was always available to 
provide assistance throughout the project. My colleagues, Drs. 
Susan Martin, Michael Hilton, and Gayle Boyd provided support 



XI 



during the planning and implementation of the working group. 
The Prevention Branch Chief, Jan Howard, provided us with 
valuable guidance and the necessary resources to complete this 
project. In addition, she brought together the final thoughts for 
the research agenda, which are found in the last paper in this 
monograph. Len Epstein, Managing Editor, arranged for the joint 
collaboration of this monograph. Finally, special thanks goes to 
Loran Archer, former Deputy Director, NIAAA, who reviewed 
the entire manuscript in draft form. 



Phyllis A. Langton, Editor 
The George Washington University Sociology Department 

Washington, D.C. 



Xll 



Parti 

Introduction and Overview 



h i 

■ 



1 



Applying a Participatory 

Research Model to Alcohol 

Prevention Research in 

Ethnic Communities 

Phyllis A, Langton and Elsie G. Taylor 



Introduction 

The prevention of alcohol-related problems in ethnic communi- 
ties is an area where the interests of research scientists, service 
professionals, community strategists, and policv makers inter- 
sect. Yet, there has been limited community-based research on 
the prevention of alcohol-related problems in ethnic communi- 
ties. Alcohol prevention research has been dominated bv surveys 
of individuals in which some ethnic groups have been unevenlv 
represented in the population samples or in the analysis (Ja and 
Aoki, 1993; Moskowitz, 1989). While national surveys have found 
disproportionately high levels of alcohol consumption among 
some ethnic groups, some of these surveys have been criticized 
for producing unreliable, invalid data on ethnic groups and for 
failing to provide contextual information. 

Some research scientists are conceptualizing the study of 
alcohol-related problems using a public health model. This 
model contains three elements: (1) the agent — alcohol beverages 
or ethanol itself, (2) the individual — host, and (3) the environ- 
ment — the physical, interpersonal, or social milieu surrounding 



the use of alcohol. Using this model, research scientists study 
interactions among the three elements. The unit of analysis shifts 
from the individual to the community. 

Using the public health model to the prevention of alcohol- 
related problems in ethnic communities follows a growing tradi- 
tion in other fields of health and illness research. For example, 
the effectiveness of this approach has been shown in the area of 
cardiovascular disease(see Farquhar et al., 1985). There have been 
reductions and modification of smoking habits, eating habits, 
and even the control of high blood pressure that have followed 
from the application of this model to the community. 

The public health model was central to the working group 
that the National Institute on Alcohol Abuse and Alcoholism 
(NIAAA) convened in May 1992. This working group examined 
methods for prevention of alcohol-related problems in ethnic 
communities. Research scientists, service professionals, and com- 
munity strategists convened in Washington, DC, in May 1992, 
representing four major ethnic groups: (1) Native Americans 
and American Indians, (2) Hispanics, (3) African Americans and 
Black Americans, and (4) Asian Americans and Pacific Islanders. 
The following objectives of the working group were part of 
NIAAA's general goal to frame a research agenda: 

• to facilitate and stimulate intervention and preintervention 
research on alcohol-related problems in ethnic communities; 

• to understand ethnic communities as unique resources for 
effecting certain types of social and behavioral change; 

• to identify a model of participatory research that would 
facilitate collaboration between research scientists, service 
professionals, and community strategists; 

• to understand the process of information transfer with 
respect to ' 'proven" and promising prevention strategies 
in ethnic communities. 

The organization and conceptualization of this working group 
were shaped mostly by the responses of the invited participants 
from the four major ethnic communities. The structure provided 
all groups the opportunity to identify the most effective ways to 
conduct research to benefit the ethnic and research communities. 
This paper has several objectives: (1) to identity the major 
concepts that framed the research agenda of the working group, 



(2) to examine the controversy over the definitions of race and 
ethnicity, (3) to develop a model of participatory research to be 
used in alcohol prevention research, and (4) to identify some 
methodological challenges for applying a participatory research 
approach to the prevention of alcohol-related problems in ethnic 
communities. 

Concepts 

The concepts central to this monograph are: cultural sensitivity, 
cultural competence, community, and ethnicity and race. 
Research scientists, service professionals, community strategists 
and representatives, policy makers, and administrators use these 
concepts in varying ways. Consequently, there are multiple 
definitions and meanings imputed to these concepts. 

In this paper, concepts and definitions are interpreted as 
attempts to describe the essence of ideas, not as pronouncements. 
In the alcohol prevention literature, there is sometimes a finality 
associated with the definition of a concept that may be inappro- 
priate. For example, Babor (1990, p. 33), in an essay to define 
alcohol dependence, argues there is no universally valid or verid- 
ical view of dependence. Therefore, there is no universally valid 
or veridical way of evaluating these definitions. What exists 
instead are culturally specific perspectives associated with social 
constructions of dependence, each of which predicates a different 
type of meaning. 

The preceding description is appropriate to the concepts that 
guided the working group. For example, the social science litera- 
ture shows that there never has been a clear cut, universally 
accepted definition of community, just a consensus of what the 
term connotes. It is, however, important to examine which 
groups control the defining process and how these groups use 
definitions to promote their own ends. Definitions have implica- 
tions, and different defining groups are promoting different ideas 
through their definitions. Thus, it is not surprising that, in this 
monograph, concepts and definitions sometimes have different 
meanings for the contributors, who represent a variety of back- 
grounds and perspectives on the prevention of alcohol-related 
problems in ethnic communities. 



Cultural Sensitivity 

Within the last decade, the concept of cultural sensitivity has 
become a very popular one for service professionals and some 
research scientists. There is a wide range of terms used by 
researchers in many settings for operationalizing cultural sensi- 
tivity. Some of these terms include cultural identity or cultural 
acumen. Orlandi et al. (1992, p. VI) define cultural sensitivity as 
an awareness of the nuances of one's own and other cultures. 
Gilbert, in this volume, defines cultural sensitivity as an aware- 
ness by the alcohol researcher that a targeted cultural group may 
perceive alcohol use differently from the researcher. 

Cultural Competence 

The concept of cultural competence is the subject of the first 
volume of CSAP's Cultural Competence Series (1992). In this 
series, cultural competence is a set of academic and interpersonal 
skills that allow individuals to increase their understanding and 
appreciation of cultural differences and similarities within, 
among, and between groups (Orlandi et al., 1992, p. VI). This 
requires a willingness and ability to draw on community-based 
values, traditions, and customs and to work with knowledgeable 
persons from the community in developing prevention activities- 
(Hewitt, 1993, p. 5). The population to be served may include 
any group that has an established set of norms, values, beliefs, 
and practices that define the identity of that group. 

Cultural competence means more than that persons of a cer- 
tain ethnicity or speakers of a particular language should be 
employed in a given research project. It means, for example, that 
researchers work in collaboration with community members to 
develop culturally appropriate interventions and data collection 
procedures. In this way, questions of the validity of including 
culturally competent strategies can be evaluated and tested. 

In this volume, the concept of cultural competence is central 
to the papers of Drs. Gilbert and Moran. Gilbert defines cultural 
competence as deliberate actions taken by researchers to develop 
an understanding of cultural similarities and differences in 
research populations. This includes the systematic integration 



into research designs of theory and methods that reflect these 
variations. Moran adds that researchers need to conduct them- 
selves in a way that is congruent with the behaviors that members 
of a cultural group recognize as appropriate among themselves. 
However, this does not mean that researchers behave as though 
they are members of the cultural group. 

Community 

People's desire for a community in which they can control the 
decisions that affect their lives has always been a part of the 
very nature of society. The idea of community derives from the 
Latin COMMUNITAS, meaning "common or shared" (Labonte, 
1989, p. 87). Many definitions of community have been used 
(Giesbrecht et al., 1990; Hillery, 1954; see Holder, 1992, for a 
review of definitions in sociology, political science, and social 
work). There has been no clear, universally accepted definition 
of community, rather just a consensus of what the term connotes. 

Community is more than some demographic datum; it is the 
interaction of people working to share decisions and responsibili- 
ties. Thus, community is organization, in that it is a group of 
people sharing values, institutions, and resources. Bell and 
Newby (1971) define community as a culture that includes val- 
ues, norms, and attachment to the community as a whole, as 
well as to its parts. This definition separates communities from 
mere aggregates of people, who may not share common goals. 
It also assumes that a community forms a whole greater than 
the sum of the individuals within it. 

Like other concepts used in alcohol prevention research, the 
crucial point is that the concept of community be explicitly clari- 
fied and not remain implicit. Only then is it possible to identify 
how to bring about intervention through a community rather 
than intervention in the community. 

The Controversy Over Definitions of 
Race and Ethnicity 

The concepts of ethnicity and race pose many conceptual and 
measurement challenges. First, according to Hahn (1992), the 






categories of race and ethnicity are not consistently defined and 
ascertained by federal data-collection agencies. Second, there are 
indications that popular notions of race and ethnic categories 
differ greatly from those of researchers, data collection agencies 
and the public. For example, the category "White" is sometimes 
understood by Hispanics to mean "Anglos," and not Hispanics. 

Third, survey enumeration, participation, and response rates 
are not similar for all racial and ethnic populations (Hahn, 1992). 
In the 1980 census it is estimated that blacks were undercounted 
by 5.9% and Hispanics were undercounted by as much as 7.8% 
(Fay et al., 1988). There is also evidence that individual responses 
to questions of racial and ethnic identity shift over time. For 
example, a shift in perception of identity was found in some 
answers to the 1980 census race question. An analysis of Census 
data of 1980 shows that 26.5 million people identified themselves 
as "Black or Negro/ 7 while only 21 million claimed African 
American ancestry (Hahn, 1992). 

Apparently some of these problems were corrected by the 
1990 census. William Hunt, Director, Federal Management 
Issues, Government Accounting Office, testified before the Sub- 
committee on Census, Statistics, and Postal Personnel that federal 
agencies generally use consistent race and ethnic definitions 
(1993, p. 2). However, some problems associated with collecting 
data on Hispanics continued to occur as these had with the 
1980 census. 

Several researchers studying alcohol and other drug use have 
reviewed the varying concepts and meanings of ethnicity and 
race available in the social science literature (see, for example, 
Cheung, 1990-91a, b; Heath, 1990-91). They document the lack 
of conceptual clarity and consensus as to what researchers mean 
by ethnicity and race and how these concepts have been used 
in research. Cheung (1990-1991b, p. 582) argues that studies of 
ethnicity and drug use, including alcohol use, have not come to 
grips with the complex phenomenon of ethnicity. He adds that 
the inadequate conceptual and operational treatment of ethnicity 
has been greatly responsible for the lack of attempts in most 
studies to explain ethnic variations in drug use. 

Heath (1990-1991, p. 609) states that attempts to deal with 
"ethnic groups," "ethnicity," and related concepts have not been 



8 



as informative as many social scientists had hoped and expected. 
The literature that examines differences in drinking patterns 
among various ' 'ethnic groups" in the United States is logically 
inconsistent because differentiation of categories is not based on 
any uniform criteria. 

Consequently, there are many problems in doing compara- 
tive studies within and across ethnic groups. We need to recog- 
nize in alcohol prevention studies the cultural diversity within 
and among ethnic groups, as well as similarities among the 
groups. Similarities among ethnic groups are noted in that the 
drinking practices of ethnic minority groups do not shape nor 
necessarily reflect the normative patterns of mainstream groups 
in the United States. A second similarity among the ethnic groups 
is the frequent "ghettoization," in a political and economic sense, 
of communities that are labeled as "Koreatowns" and "China- 
towns." A third similarity is the extent to which alcohol outlets 
tend to congregate in some ethnic communities. 

As previously noted, diversity within ethnic and racial groups 
exists. During a working group discussion of the papers on Black 
Americans and African Americans, several African American 
perspectives were evident. African American communities are 
not monolithic. 

This diversity gives rise to some questions: Is there a need 
for standardized identification of race and ethnicity in databases? 
Is this possible to accomplish? Is ethnicity measurable? In April 
1993, William M. Hunt, testified to the Subcommittee on Census, 
Statistics, and Postal Personnel that race and ethnic data are 
among the most complex and controversial data collection efforts 
undertaken by the Federal Government. Furthermore, he argues 
that race and ethnicity are not objectively definable characteris- 
tics, which makes measurement difficult. As ethnic populations 
grow and change, biracial and multiethnic children of intermar- 
riages are likely to increase, making precise measurement even 
more difficult. These problems may result in increasing pressure 
from new groups for identification on the census form (Hunt, 
1993, p. 2). 

Peterson (1987, p. 232), a demographer, argues that there is 
no way of achieving a classification of ethnic groups that satisfies 



all of the important governing principles of science, law, politics, 
and expediency. He describes the job of the Bureau of the Census 
as a mission impossible, and not one of its own choosing. 

For this working group, the major ethnic groups were 
selected from those in the Ethnic Minority Announcement of 
1991 published by NIAAA, and those ethnic and racial groups 
identified by the Federal Government census classifications as 
the four largest and most widely recognized ethnic and racial 
groups: (1) Black Americans, (2) Hispanic Americans, (3) Ameri- 
can Indians and Alaska Natives , and (4) Asian Americans and 
Pacific Islanders. However, there is some degree of inconsistency 
among the contributors to this monograph who use different 
terms when describing the same ethnic groups. 

The definitions of race and ethnicity that guided some con- 
tributors to this monograph are drawn from the definitions of 
Hewitt (1993, p. 5) and Orlandi et al. (1992, p. VI). Race is a 
socially defined population that is derived from distinguishable 
physical characteristics that are genetically transmitted. In the 
same volume, ethnic is defined as belonging to a common 
group — often linked by race, nationality, and language — with a 
common cultural heritage and /or derivation. 

In sum, in health research and in the prevention of alcohol- 
related problems, populations are commonly divided by catego- 
ries of race and ethnicity. This categorization assumes that race 
and ethnicity are valid concepts that can be correctly identified 
(Hahn, 1992). This has not been proved to date. It is possible 
that race and ethnicity cannot be readily assessed using survey 
techniques. 

Participatory Research: 
A Rational 

There are several methods of scientific inquiry and many versions 
of doing scientific research, depending upon the research situa- 
tion, the researchers, and the phenomena being studied. Episte- 
mologies of science and the techniques of data collection and 
analysis have considerable effect on what we study, how we 
study it, and how we relate to "subjects" (Chesler, 1991, p. 758). 



10 



In the formulation stage of the working group, several partici- 
pants voiced the view that much of the research produced by the 
scientific community was not useful to practitioners, to program 
strategists, or to service agencies in ethnic communities. Because 
of their experience with academic researchers, these service pro- 
fessionals were concerned that, again, their voices would not be 
heard over those of research scientists. This view is reinforced 
by Johnson (1993, p. 27), who notes that many clinicians in the 
alcohol field voice the same concern. Research scientists' knowl- 
edge about alcohol problems does not ring true to the clinician's 
experience with alcohol users in the community outside the 
research world. 

A partial explanation for these views is grounded in the 
community members' experiences and perceptions of how 
research scientists conduct their research in ethnic communities. 
First, the traditional mode of scientific inquiry used by academic 
researchers and its accompanying methods often do not fit the 
nature of ethnic communities and their goals of social change. 
Second, the traditional scientific model does not involve partici- 
pation by the community in the identification of the prevention 
intervention. Third, ethnic communities are not organized with 
sets of rules for the accumulation of scientific knowledge. Such 
rules are largely quantitative, and more closely approximate 
secondary relationships rather than the primary relationships 
that are often characteristic of ethnic communities. Finally, the 
traditional model of research serves to maintain the power of 
academic researchers to control the knowledge generation pro- 
cess and, consequently, the alcohol prevention interventions to 
be imposed on the ethnic communities. 

The participatory research model seems to fit with the pur- 
pose that many contributors to this monograph hold: bringing 
about intervention through rather than in a community. If we are 
to meet the second objective of this working group, to better 
understand ethnic communities as unique resources for effecting 
certain types of social and behavioral change, then more than 
one model is likely to be useful to improve both our academic 
and practical knowledge of the social, economic, political, and 
cultural diversity of ethnic communities. If we are to be effective 



11 



in alcohol prevention interventions, it is necessary to understand 
the richness of experience, for example, of growing up Black or 
Hispanic in White America. An opportunity to understand this 
diversity is lacking in the statistical generalizations derived from 
epidemiological surveys, which are rarely of practical value to 
prevention and treatment designers (Gilbert, 1993, p. 3). 



The Participatory Model 



There are many definitions of participatory research. One pre- 
vention researcher defines it as "research in which members of 
the intervention population share equally with researchers in 
research planning, implementation, evaluation, and dissemina- 
tion of results" (DeCambra et al. 1992, p. 3). Using this conceptu- 
alization and the ideas of Chesler (1991), a participatory model 
is developed and discussed below. 

A comparison between the traditional research model and 
the participatory model is offered as a way to enlarge the options 
that prevention researchers consider when attempting to bring 
about intervention through rather than in a community. A com- 
parison of two models of scientific inquiry in Figure 1-1 provides 
a basis for exploring the application of a participatory model to 
the study of alcohol prevention research in ethnic communities. 
These models, or "ideal types," rest upon the assumptions under- 
lying two modes of scientific inquiry: deduction and induction 
(Strauss, 1987). 

The traditional model of research is grounded in deductive 
inquiry. As shown in Figure 1-1, the goal of research is to advance 
academic knowledge by applying the basic rules of verification, 
including standardized measurement devices, and the establish- 
ment of "distance" between the investigator and the field of 
study. The research process is controlled by the researcher, and 
the research results are published in scientific journals. The tradi- 
tional research model has been and continues for many research 
scientists to be the model "par excellence" for maintaining the 
scientific integrity necessary for the cumulation of knowledge. 
A participatory research model is grounded in inductive 
inquiry. As shown in figure 1, the goal of research is to advance 



12 



Figure 1-1 

ALTERNATIVE MODELS IN ALCOHOL PREVENTION RESEARCH 

Traditional Research Participatory Research 



Goals 



Advance Academic 
knowledge 



Advance practical 
knowledge 



Evaluation ot services Intervention 



Methods 



Positivist and 
deductive 

Standardized 

measurement 

Replicability 

Experimental design 



Interpretive and 
Inductive 

Measures generated in 
response to local 
situation 



Quasi-experimental 
design 



Researcher/ 
Community 
Relationships 



Researcher 
controlled 

Researcher separate 
trom the community 

Objective through 

distance 



Co-control 

Researcher a part of 
the community 

Objectivity through 
reflexivity 



Research Subjects Passive subjects 



Active subjects 



Research Issues 



Determined ahead 
of time 



Evolving from 
experience in the 
community 





Demonstrate group 
"effectiveness" 


Interventions through 
the community 


Research Funds 


Controlled by 
granting agencies 


Co-control; access to 
resources 


Data Ownership 


Researcher owned 


Community and 
Research 


Research products 


Scientific articles in 


Community reports 
scientific journals and 
interventions 



This figure is adopted from the models of Chesler (1991) ond DeCambra et ol, 
(1992). 



13 



practical knowledge and to provide interventions through the 
community. The community shapes the research process by 
actively participating with the researchers in all phases of 
research development. Ethnic groups are included at all levels 
from investigators to interviewers (DeCambra et al, 1992, p. 8). 
The research process itself takes on different dimensions when 
the participants help to define the interventions. This is illus- 
trated again by the models that follow. 

Singer (1993, p. 19), an anthropologist, compares a researcher- 
centered model and a community-centered model. These models 
closely approximate the two models in figure 1. He describes the 
research-centered model as university and academically based 
research, guided by the interests of the researcher, who is the 
primary beneficiary of the public and professional recognition 
bestowed on the research. Furthermore, the academic researcher 
decides if and in what form the findings will be available to the 
participants. Often, the researchers leave little of value in the 
community when the research is completed. This description by 
Singer is similar to the traditional model shown in figure 1. 

The community-centered model described by Singer closely 
approximates the participatory research model in figure 1. 
Researchers and community members engage in continuous dis- 
cussion as a team to identify the issues and concerns as perceived 
by members of the community. In addition, an effort is made to 
develop the research skills of the ethnic community members. 

Participatory Research in Alcohol 
Prevention Research 

A participatory research model in which research scientists and 
service professionals in the community collaborate to decide 
the prevention strategy is likely to increase the opportunity for 
researchers to gain access to ethnic communities and to develop 
relationships based on trust. These relationships are necessary 
for the development and testing of prevention strategies in ethnic 
communities (Kelly, 1988). 



14 



Access and Trust 

Access to do research in ethnic communities is a complex issue. 
As the contributors to this monograph demonstrate, many ethnic 
communities have experienced negative relationships with 
researchers, who have shown more interest in their own research 
than in the welfare of the community. For example, if researchers 
lack sensitivity to the history of the community, they are unlikely 
to attain access very easily. Furthermore, they may create a 
response from the community that will keep others in the future 
from gaining access. A few of the members of the working group 
reported that communities often perceive that academic 
researchers view the community as a field laboratory to be used 
primarily for the benefit of the research community. This may 
result in researchers publishing results about a community that 
portray the community in a negative or stereotyped way. Under 
these perceptions, the community is not likely to grant access 
to research scientists to conduct further studies. 

Language differences, lifestyle differences, and the time 
dimension often create social distance between academic 
researchers and ethnic communities. Often members of ethnic 
communities report that academic researchers do not work with 
the community to find out what the community needs. It takes 
time to develop a sense of community and time to develop 
outside community relationships. 

Trust is one of the most important variables in how an ethnic 
group evaluates a potential researcher(Perkins and Wanders- 
man, 1990). If we are to gain access and develop trust from 
community members, research scientists need to be knowledge- 
able of the social organization and the lifestyle in these communi- 
ties. The use of a participatory research model will more likely 
result in better understanding of the unique resources for effect- 
ing certain types of social and behavioral changes in ethnic com- 
munities. 

Participatory Research: 
Methodological Challenges 

Giesbrecht and Ferris (1993) argue that the negotiation of commu- 
nity-based research projects presents great potential and great 



15 



risk. Acknowledging this, it is especially important at this stage 
of our knowledge to understand and analyze the social processes 
that take place in the interaction between research scientists and 
community members. It is in the interaction process where the 
prevention of alcohol-related problems can be found. It is in the 
interaction and negotiation processes where the hazards lie. 

Many methodological challenges for applying a participatory 
research model to alcohol prevention research are identified in 
this monograph. The following list of issues grew out of the 
working group discussions. These need to be addressed in a 
systematic and critical way before the participatory model will 
be viewed as a legitimate mode of scientific inquiry by 
research scientists: 

• The limitations and strengths of the participatory model 
for meeting the two goals of advancing scientific knowl- 
edge and advancing practical knowledge; 

• The need to address the mix of research scientists, service 
professionals, and community strategists on investigator 
review boards to improve the peer review process and 
funding opportunities for community organizations; 

• The need for additional funding of research projects neces- 
sary to allow the time that may be needed to include com- 
munity participation in the multiple phases of the research 
process; and 

• The need to increase the negotiation skills of research scien- 
tists and service professionals to include the concepts of 
cultural sensitivity and cultural competence. 

A participatory research model in which research scientists, 
service professionals, and community strategists collaborate to 
decide the prevention strategy is likely to increase the opportu- 
nity for researchers to gain access to ethnic communities and to 
develop relationships based on trust. We need to validate 
whether access and trust are necessary elements for the testing 
of prevention strategies in ethnic communities. 

The ideology of the participatory research model is appealing 
to service professionals, to community strategists, and to some 
researchers. However, we need to conduct systematic research 
on the participatory research process itself before accepting it 



16 



as appropriate to alcohol prevention research. Research on the 
"participatory research model" will require institutional innova- 
tion within NIAAA, which has been committed to a traditional 
research model. To do this research will require the acceptance 
by those in power that the model is appropriate to investigate. 
Finally, researchers who are engaged in developing more 
innovative approaches and models in alcohol prevention 
research at the community level might benefit from the wisdom 
of Vanderveen: "To know what one is about and why, is probably 
the most rudimentary common sense ground rule for all who 
would participate in science" (1993, p. 31). 

Contents of the Monograph 

The contents of this monograph follow the agenda of the working 
group. The monograph presents the state-of-the-art findings on 
alcohol prevention research in four major ethnic communities 
as of 1992: American Indians and Alaska Natives, Hispanics, 
African Americans, and Asian Americans and Pacific Islanders. 
Research scientists, service professionals, and community strate- 
gists collaborated in the working group to explore explanations 
for these findings, and to frame an agenda for future research. 

The remainder of this monograph is divided into four sec- 
tions. In Part II, Dr. Gilbert and Dr. Moran review the meanings 
of cultural sensitivity and cultural competence. They show how 
these meanings are related to community intervention in ethnic 
communities. Dr. Robinson, a public health professional, is the 
discussant for these papers on cultural sensitivity. He argues 
that researchers need to understand the historical context of 
the communities in which they are trying to conduct research. 
Without this sense of history, scientists are at risk of being insensi- 
tive when conducting their research. 

Four papers in Part III address conceptual and methodologi- 
cal issues of conducting alcohol prevention research in ethnic 
communities. In the first paper, Dr. Pentz compares and contrasts 
the various models of community research that have been tried, 
and the implications of alternative models for prevention 
research in ethnic communities. In the second paper, Dr. Beauvais 



17 



presents an argument for the building of an alliance between 
the two cultures of science and community so that each culture 
enriches the other. He addresses several methodological issues 
related to this alliance that are important for the effective blend- 
ing of these cultures. The third paper in Part III, by Dr. Schinke 
and Ms. Cole, is an addition to the monograph. We recognized 
after the working group that we needed to direct more attention 
to methodological principles when conducting culturally sensi- 
tive alcohol prevention in ethnic communities. The last paper in 
Part III provides an analysis of a successful prevention research 
partnership. Dr. Rolf, a research scientist, describes in depth each 
step of the research process. He shows how his research team 
was able to bridge the gaps between researchers and community 
strategists by integrating methods, strategies, and the needs of 
each group. He demonstrates the necessity of collaboration 
among all members of the research team and the community 
members. 

The four major case studies on American Indians and Alaska 
Natives, Hispanics, African Americans, and Asian American and 
Pacific Islanders are presented in Part IV. Within each case study 
there are three papers written by: (1) an academic research scien- 
tist who presents the state of the art findings on alcohol preven- 
tion research, (2) a community researcher or service professional 
who focuses on specific community studies and findings, and 
(3) a discussion paper authored by a community strategist from 
the ethnic community. In Part V, the Chief of the Prevention 
Research Branch, NIAAA, Jan Howard, concludes the mono- 
graph with her paper on Framing the Research Agenda. 

References 

Babor, T. Social, scientific, and medical issues in the definition of alcohol and 
drug dependence. In: Edwards, G., and Lader, M, eds. The Nature of Drug 
Dependence. New York: Oxford University Press, 1990, pp. 19-40. 

Bell, C, and Newby, H. Community studies: An Introduction to the Sociology of 
the Local Community. New York: Praeger, 1971. 

Chesler, M.A. Participatory action research with self-help groups: An alterna- 
tive paradigm for inquiry and action. American Journal of Community Psychol- 
ogy, 19:757-786, 1991. 



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Cheung, Y.W. Overview: Sharpening the focus on ethnicity. The International 
Journal of the Addictions, 25 (5A & 6A):573-579, 1990-91a. 

Cheung, Y.W. Ethnicity and alcohol/drug use revisited: A framework for future 
research. The International Journal of the Addictions, 25 (5A & 6A):581-605, 
1990-91b. 

DeCambra, H.; Enos, R.; Matsunaga, D.S.; and Hammond, O.W. Community 
involvement in minority health research: Participatory research in a native 
Hawaiian community. Cancer Control Research Reports for Public Health, 2-9, 
October 1992. 

Farquhar, J.W.; Fortmann, S.P.; Maccoby, N.; Haskell, W.L.; William, W.T.; 
Flora, J.A.; Taylor, C.B.; Brown, B.W.; Solomon, D.S.; and Hulley, S.B. The 
Stanford Five-City Project: Design and methods. American Journal of Epidemi- 
ology, 122:323-334, 1985. 

Fay, R.E.; Passel, J.S.; Robinson, G.J.; and Cowan, CD. The Coverage of the 
Population in the 1980 Census. Washington, DC: Bureau of the Census. US 
Department of Commerce, Publication PHC80-E4, 1988. 

Giesbrecht, N., and Ferris, J. Community-based research initiatives in preven- 
tion. Addiction, 88:83S-93S, 1993. 

Giesbrecht, N., et al. Research, Action, and the Community: Experiences in the 
Prevention of Alcohol and Other Drug Problems. United States Department of 
Health and Human Services, 1990. 

Gilbert, M.J. Anthropology in a multidisciplinary field: substance abuse. Social 
Science and Medicine, 37:1-3, 1993. 

Hahn, R.A. The state of federal health statistics on racial and ethnic groups. 
Journal of the American Medical Association, 267:268-271, 1992. 

Heath, D.B. Uses and misuses of the concept of ethnicity in alcohol studies: 
An essay in deconstruction. The International Journal of the Addictions, 25(5A 
& 6A):607-628, 1990-91. 

Hewitt, W. Cultural competence: An interview with Warren Hewitt. Journal of 
Psychoactive Drugs, 25:5-7, 1993. 

Hillery, G.A., Jr. Definitions of community: Areas of agreement. Rural Sociology, 
111-123, 1954. 

Holder, H.D. What is a community and what are implications for prevention 
trials for reducing alcohol problems? In: Holder, H.D., and Howard, J.M. 
Community Prevention Trials for Alcohol Problems. Westport, Conn: Praeger, 
1992, pp 15-33. 

Hunt, W. Federal Data Collection: Measuring Race and Ethnicity Is Complex and 
Controversial, GAO/T-GGD-1993-21. 

Ja, D., and Aoki, B. Substance abuse treatment: Cultural barriers in the Asian- 
American Community. Journal of Psychoactive Drugs, 25:61-72, 1993. 

Johnson, P.B. The value of ethnographic alcohol studies: A psychologist's per- 
spective. Social Science and Medicine, 37:27-30, 1993. 



19 



Kelly, J.G. Preface. Prevention in Human Services, 6:3, 1988. 

Labonte, R. Community empowerment: The need for political analysis. Cana- 
dian Journal of Public Health, 80:87-88, 1989. 

Moskowitz, J.M. The primary prevention of alcohol problems: A critical review 
of the research literature. Journal of Studies on Alcohol, 50:54-88, 1989. 

Orlandi, M.A., ed. Cultural Competence for Evaluators: A Guide for Alcohol and 
Other Drug Abuse Prevention Practitioners Working with Ethnic/Racial Commu- 
nities. United States Department of Health and Human Services, OSAP, 1992. 

Perkins, D., and Wandersman, A. You'll have to work to overcome our suspi- 
cions. Social Policy, 32-41, 1990. 

Peterson, W. Politics and the measurement of ethnicity. In: Alonso, W. and 
Starr, P. The Politics of Numbers. New York: Russell Sage Foundation, 1987, 
pp. 187-233. 

Singer, M. Knowledge for use: Anthropology and community-centered sub- 
stance abuse research. Social Science Medicine, 37:15-25, 1993. 

Strauss, A. Qualitative Analysis for Social Scientists. Cambridge: University 
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Vanderveen, T. Epilogue. Social Science and Medicine, 37:31, 1993. 



20 



Part II 

Cultural Issues in Community- 
Based Prevention Research 



i 



i 



2 

Conducting Culturally 

Competent Alcohol 

Prevention Research in 

Ethnic Communities 



M. Jean Gilbert 



Introduction 

The terms "cultural sensitivity" and "culturally relevant" have 
been in use among researchers and service providers for at least 
20 years amid some confusion about what they actually mean. 
More recently, the term "cultural competence" has entered the 
diversity lexicon (Orlandi,1992). In the past, these terms have 
usually been operationally defined to mean that more persons 
of a certain ethnicity or more speakers of a specific language 
should be employed when a given service arena or research 
project is targeted to persons of that ethnicity. Without a doubt, 
participation by members of an ethnic group in the planning 
and conduct of services or research directed toward that group 
is one important component in making services and research 
appropriate and sensitive to group members. Certainly concern 
for language differences is also critical. However, an understand- 
ing of cultural sensitivity, relevancy, and competency in research 
design rests on a much more complex basis than just these two 
components. These terms derive their essential meanings from 



23 



the concept of culture: what culture is and the important ways 
that cultures resemble and differ from each other. 

A more precise understanding of the meaning of these cul- 
tural diversity terms and the issues they raise for research there- 
fore requires a brief initial outline of what is generally understood 
about the nature of culture. Following this discussion, the cultur- 
ally associated terms are more fully defined as they are related 
to the research process itself. The critical need for firsthand expe- 
rience with the cultural group to be studied is stressed, along with 
the value of this kind of experience. School-based prevention 
programs and their evaluations exemplify the way researchers 
have ignored the multiethnic character of the youthful popula- 
tion, as the next section of the paper points out. Suggestions for 
more culturally sensitive prevention research designs in school 
settings are offered. Finally, an argument is made for collabora- 
tion among researchers, providers, and community members for 
the conduct of culturally competent prevention research. 

Alcohol Use in the Context 
of Culture 

Culture may be thought of as all the ways a specific group of 
people adapts to its unique geographic, physical, historical and 
social niche. A culture is learned by its members, largely through 
the medium of language and interaction, than inherited biologi- 
cally. Much cultural learning occurs out of awareness, through 
countless acts of modeling and reinforcement — the way, for 
example, most Anglo-Americans in the United States learn that 
the ' 'proper 7 ' distance between people in friendly conversation 
is about 2 1 /2 to 3 feet, a distance greater than a Middle Easterner 
would consider comfortable. The process of cultural socialization 
of group members is not confined to the enculturation of the 
young, but is ongoing across the life cycle, mediated by peer 
modeling and pressure as well as group response to historical 
and structural factors. 

The term "ethnic group" is used to designate a group of 
people with shared understandings and life ways. Unlike the 
terms "race" and "nationality," which denote groups defined 



24 



(however imperfectly) by biological and geo/ political bound- 
aries, the boundaries between ethnic groups are social construc- 
tions created by member self-identification and allegiance to 
group beliefs and norms. In this paper, the terms "ethnic group/' 
"culture" and "cultural group" are used interchangeably to 
emphasize this relationship. 

The distinctive material manifestations of a culture, such as 
food, dress, and technology, are readily perceived by persons 
outside the culture. It is usually not difficult for people to become 
sensitive to these visible aspects of a culture and to understand 
their practical implications. For example, most health care pro- 
viders can readily accept the good sense of discussing dietary 
practices with immigrant Vietnamese or Cuban patients in terms 
of the foods that make up their specific cuisines rather than 
referring automatically to mainstream American food habits. 

However, the most important characteristics of a culture are 
less easily grasped. These are abstract values, beliefs, and percep- 
tions about reality — culturally unique frameworks of interre- 
lated meanings and social constructions. These abstractions are 
shared to a greater or lesser degree by members of a cultural 
group (the way a language is shared) and, when acted upon, 
produce behaviors considered appropriate and acceptable within 
that group. These invisible features of a culture function together 
as an integrated whole, each shaping and reinforcing the others. 
For example, the unique values of a group will be supported by 
norms, that is, rules governing behaviors such as alcohol use. 
The norms then will be reinforced by sanctions that provide social 
consequences for following or breaking the norms. 

Through language, members of cultural groups learn to cate- 
gorize and classify objects, ideas, persons, events, and experi- 
ences in culturally unique ways. These cognitive categories and 
the relationships among them form systems of meaning. The 
assumptions and premises that make up such a cultural world 
view are internalized to the point that the members of a culture 
believe their perspective is "reality" and their view of human 
behavior to be a priori "human nature." So buried are many of 
these guiding premises that they form a deep structure that 
shapes thought and behavior unconsciously. Thus it is exceed- 



25 



ingly difficult for researchers and service providers who have 
learned to construct reality through one set of classifications, 
categories, and meanings to imagine a reality constructed differ- 
ently or to place the behavior of persons from another culture 
into a meaning or motivational context other than their own. 

The reality of core orientations around which a cultural world 
view is framed does not mean a culture is static and non-respon- 
sive to changes caused by alterations in the social or physical 
environment. Cultures are modified, sometimes rapidly, some- 
times slowly, by cumulative adaption to changed circumstances. 
Further, individuals within cultures may accept, variously inter- 
pret, or refute aspects of their cultural background. Through 
culture contact, individuals and whole groups may blend or 
adapt elements from two or more cultures. However, change 
occurs most rapidly in material culture and very much more 
slowly with respect to cognitive structures, meaning systems 
and interaction patterns. 

The cultural meanings surrounding a specific trait such as 
alcohol use are derived from just such relational matrices. Alco- 
hol use has been nearly ubiquitous in the societies of the world; 
hence most cultures have complex sets of premises and assump- 
tions that guide initiation, normal and deviant use, and the per- 
ceived role of alcohol in social interactions. There is plentiful 
evidence that alcohol-related norms and behaviors vary and are 
integrated differently across cultural and subcultural groups 
(Heath, 1987). Communicating, assessing, and measuring pre- 
vention effects in a specific population becomes problematic if 
cultural motivations and meanings around alcohol use are not 
understood and reflected in program design and evaluation. 
From a scientific point of view, the internal validity of research 
measures may be seriously threatened. 

Cultural Sensitivity, Relevancy, and 
Competency Redefined for 
Alcohol Research 

The terms relating to culture cited earlier in this paper can now 
be better understood. Cultural " sensitivity' ' refers to an aware- 



26 



ness by the alcohol researcher that a targeted cultural or subcul- 
tural group may very likely perceive alcohol use in a relational 
context different from his/her own and that modifications may 
need to be made in research strategies to accommodate those 
differences. Cultural "relevance" means that a concept, preven- 
tion modality, or research strategy must be salient to the group 
to whom it is directed, that is, understandable in their terms. 
Cultural "competence" embodies both concepts in deliberate 
actions taken by researchers to develop an understanding of 
cultural similarities and differences in research populations and 
to systematically integrate into research designs theory, strategies, 
and methods that reflect these variations. 

Lloyd Rogler, director of the Hispanic Research Center at 
Fordham University, has given us an excellent description of 
culturally competent research (Rogler, 1989). In this brief article 
Rogler's major point, and it is absolutely critical, is that no specific 
act or set of finite acts performed on research makes it "culturally 
sensitive." Culturally sensitive research is an ongoing, systematic 
process. He states: 

In general research is made culturally sensitive through a 
continuing and open-ended series ot substantive and meth- 
odological insertions and adaption designed to mesh the pro- 
cess of inquiry with the cultural characteristics of the group 
being studied. The insertions and adaption span the entire 
research process, from the pretesting and planning of the 
study, to the collection of data and translation of instruments, 
to the instrumentation of measures and to the analysis and 
interpretation of the data (Rogler, 1989, p. 296). 

Culturally Competent Research: 
Essential First Steps 

The first step while conducting culturally competent research is 
the hardest. Researchers need to acknowledge the possibility 
that they may know very little about research populations differ- 
ent from their own if they have not had firsthand, in-depth 
experience with the group. Acquiring essential knowledge about 
a culturally defined research population should occur before 



27 



formulation of a research design and methods. Researchers will 
need to go through the painstaking process of examining and 
comparing their own cultural assumptions with those of the 
groups they are studying at every step of the research process. 
However, no time is more critical than in the theory-building 
stage of prevention research, when hypotheses about what inter- 
ventions might be effective in a given population or across differ- 
ent populations are formulated and measures for assessing out- 
comes are designed. 

Firsthand experience is the best corrective for testing one's 
assumptions and becoming knowledgeable about groups differ- 
ent from one's own. It involves the researcher's direct immersion 
in the culture of the group to be studied. This means that the 
researcher who is designing the research (not his or her research 
assistant) needs to go to the locale where the group resides 
and /or consumes alcohol, talk to leaders of the group, have 
conversations with a wide range of alcohol consumers them- 
selves and observe settings, occasions, and actions involving 
alcohol use. It is helpful for a researcher to interview local-level 
treatment providers and health professionals, particularly those 
of the same ethnicity as the targeted group. Firsthand experience 
is greatly amplified if a research team includes one or more 
researchers drawn from the group (s) to be studied. 

The strategies used by the Western Behavioral Study Group 
at Colorado State University at Fort Collins are instructive in 
this regard (Beauvais and La Boueff, 1985; Oetting, Edwards 
and Beauvais, 1989; Edwards and Edwards, 1989). This research 
group has conducted school-based studies among a variety of 
cultural groups only after acquiring on-the-ground information 
about the structure of the local community, considering local 
leader input and assessing the local social context for alcohol 
and other drug use. These and other qualitative and archival 
data inform the design of their surveys and augment and contex- 
tualize their research findings. 

Such initial community contact is a kind of experiential pre- 
testing of theory and assumptions about what actually is going 
on within the cultural group. This step is important whether the 
researcher plans to focus exclusively on one specific ethnic group 



28 



or intends to include the group in a comparative study or survey. 
In the latter case, all the groups should be treated in this care- 
ful manner. 

Cultural Constructions in the 
Informal Sector 

On-the-ground familiarity with a target population is particu- 
larly important because most alcohol-related behavior takes 
place in the unmanaged or uncontrolled sectors of society. It is 
in this sense // insider ,/ behavior. Close attention must be paid 
to the social interactions and subjective cultural elements that 
are relevant to alcohol use within a given cultural context, and 
these do vary across and within groups. Alcohol consumption 
occurs, in the main, in the informal arena, that set of interactions 
with family, friends, and work associates that are generally 
beyond the direct control (and scrutiny) of institutions and policy 
makers (McKnight, 1987). Mauss et al. (1988), in pointing out 
that school-based prevention programs rarely have been shown 
to modify behavior or even to have long-term effects in changing 
adolescent attitudes toward alcohol use, correctly note that the 
factors most critical to the shaping of adolescent drinking behav- 
ior, such as peer influence or socialization, are imperfectly under- 
stood and are mostly beyond the purview of the school. 

Drinking is frequently woven into the content of friendship 
bonds in same-sex as well as opposite-sex social contexts, and 
the meanings and expectations attributed to alcohol use in such 
contexts is important to an understanding of how peer pressure 
influences drinking behavior. 

Then, too, alcohol use, because of its embeddedness in whole 
matrices of social meaning, often takes on symbolic or associative 
connotations that must be considered in designing interventions 
for specific groups. For example, recent research among Mexican- 
American women (Gilbert, 1991) shows that as these Latinas 
acquire higher incomes and education, usually accompanied by 
generational distance from immigrant status, more frequent and 
heavier use of alcohol is just one of many concurrent role-trans- 
figuring changes occurring in their lives. These include increased 



29 



social freedom, greater interpersonal and sexual assertiveness, 
and more participation in public life. Issues around choice and 
self-determination may thus become entangled associatively 
with alcohol use in complex ways that need to be considered in 
prevention programs and research. 

Important features of the informal social world would also 
include culturally shared beliefs about appropriate persons and 
communication strategies for socialization of youth in the use 
of alcohol as well as relevant sanctions for controlling alcohol 
use among youth and adults. For example, many cultures have 
very negative views of individualistic, autonomous decision- 
making among young or even not-so-young people. It may come 
as a surprise, then, to some prevention program designers and 
researchers that the kinds of self-assertive and self-determination 
practices designed to "inoculate" youth against alcohol and other 
drugs are not the kinds of behaviors reinforced by many Viet- 
namese, Mexican, Filipino, and Native American parents in day- 
to-day life. The effectiveness of such interventions, may thus be 
attenuated by countervailing emphases in child-rearing practices 
unknown to culturally oblivious researchers and program 
designers. 

Further, sources of individual and group self-esteem, group- 
appropriate social skills, and expression of affect, as well as 
alcohol-related problem recognition and definition, are also cul- 
turally constructed social characteristics that might be expected 
to vary, sometimes dramatically, across cultures (Fisher, 1988; 
Hall, 1976). These social features bear directly on interpretation 
and acceptance of the content and assumptions of most cognitive 
and developmental prevention strategies currently being used 
in prevention programs. Since most of the content and strategies 
are based on mainstream, middle-class Anglo social realities, the 
cultural fit of the programs may be poor (Globetti, 1989). 

Cultural premises and assumptions affect respondents 7 inter- 
pretation of questionnaire and interview protocols. It has been 
pointed out elsewhere that important cultural differences are 
not easily captured by researchers using the categories of thought 
derived from the "professional research culture ,/ (Rogler, 1989). 
Attempting to fit the social constructions of one culture into the 



30 



language and classifications of another often creates distortion 
and suppression of cultural variation (Kleinman, 1977). There is 
evidence, for example, that the meaning of Likert scale anchors 
mav van' across ethnic groups (Baranowski, Tsong and Brod- 
wick, 1990). A culturally oblivious researcher may never know- 
that respondents have not interpreted the question in the manner 
intended. Sensitivity to these issues evolves out of face-to-face 
testing, reviewing, and norming of instruments with members 
of the groups being studied. 

Unfortunately, there has been little research focused on 
uncovering inter- and intra-group differences as thev might 
relate to the cultural consonance of prevention approaches. How- 
ever, the bottom line is that policymakers, program designers, 
and researchers may create whatever programs they like, but 
their effectiveness will largely depend on the consent or ''buy- 
in" of individuals and groups within the cornmunity's informal 
sector. This they will not do if the "social map" reflected in 
programs designed to modify their behavior and research 
designed to assess its success doesn't match the "territory" of 
their social world. 

Prevention Research is Usually 
Local-Level Research 

Experiential familiarity with a research population is especiallv 
important in prevention research for another reason. Prevention 
research differs from many other types of research in that it is 
usually carried out at the local level, within a defined geographic 
region, whether it is a city, neighborhood, school district, or 
school. The approach will necessarily be based on numerous 
assumptions about the cbinking behavior and drinking contexts 
of the local-level group or groups for whom it is designed. 

From what source will these assumptions be derived? Cer- 
tainly not from national epidemiological data. Given the ten- 
dency for ethnic groups to cluster in geographical regions, local- 
level prevention research is usually focused on, say, Mexican 
Americans or Puerto Ricans (not Hispanics/ Latinos), Sioux or 
Navajos (not Native Americans), or Filipinos or Chinese (not 



31 



Asians). Much of the national epidemiological and risk factor 
data available on aggregate groups labeled Hispanics, Native 
Americans, and Asians are of marginal utility because it masks 
important differences among the highly distinct cultures within 
these aggregate categories (Trimble, 1990-91). Comparisons 
across distinct ethnic groups show that there are clear differences 
in alcohol and other drug use patterns among Cubans, Puerto 
Ricans, and Mexican Americans (Austin and Gilbert, 1989; Cae- 
tano, 1988), among Japanese, Korean, and Chinese (Chi, Lubben 
and Kitano, 1989) and among the various Native American tribal 
groups (Weisner, Weibel-Orlando and Long, 1984). There are 
also differences within each of these groups among immigrants 
and later generations. To design culturally sensitive prevention 
program assessments, the researcher needs to know a great deal 
about the specific characteristics of the cultural group in the 
particular geographic locale where the prevention program is to 
take place. 

Structural and historical factors impacting local-level cultural 
groups need to be understood by community or school-based 
prevention program planners and evaluators who want their 
projects to be culturally competent. The influence and power 
structures of cultural groups differ across communities as does 
the manner in which they are integrated into the larger commu- 
nity (Gilbert and Cervantes, 1987). Mobilizing grassroots com- 
munity support within an ethnic community around, say, liquor 
licensing policies and other controllable environmental factors 
relating to alcohol-related problem prevention requires knowl- 
edge of the influence structure within a community. Who are, 
for example, the individuals and groups capable of involving 
and mobilizing a primarily immigrant community? Are there 
historical stratifications, coalitions, and polarized perspectives 
operating within a local cultural group that could be inimical 
to the success of a community action /public health prevention 
approach and its evaluation? 

If the program is to be community-wide, targeting multiple 
cultural groups, it would be important to know how integrated 
into or alienated from the overall community are the various 
discrete populations within its geographic boundaries. Are there 



32 



barriers such as language, legal status, and economic factors 
that would limit any of the groups from being included in the 
planning, implementation, and assessment of the intervention? 
Are there deep historical divisions or resentments between 
groups that would preclude trust and cooperation? Given the 
size of the Black, Latino, and Asian populations in most urban 
areas, these would be important considerations in conceptualiz- 
ing a culturally sensitive prevention and research program 
addressed to a multi-ethnic community. Up-front research, sensi- 
tive to these possibilities, would allow for the discovery of prob- 
lems and barriers so that efforts could be made to overcome them. 
On the other hand, if the research includes a comparison 
of several communities within a geographically dispersed and 
broadly defined population, e.g., Native Americans in the South- 
west, it is important to determine whether there are structural 
or cultural features across the groups being compared that would 
render them non-comparable or would alter the basis for compar- 
ison. Attention to these issues is evident in prevention research 
conducted by Philip May et al. (1983), who, through close interac- 
tion with Native American groups, have become aware of impor- 
tant differences in the way cultural traditions in various Native 
American groups impact on drinking behavior. These research- 
ers integrate this knowledge in the design of prevention research 
projects. Stephen Schinke and his colleagues (Schinke et al., 1985) 
have conducted prevention research among several Native 
American groups with modest success, using culturally sensitive 
methods. They use an "indicated prevention modality" which 
is highly group-specific, with all curricula materials tailored to 
the cultural group. Outcome data showed reduced self-reported 
rates of alcohol, tobacco, and other drugs. 

An Example of Failure to Consider 
Cultural Issues: School-Based 
Prevention 

School-based prevention research projects seem particularly 
lacking in cultural awareness or sensitivity. The fact that youth 



33 



from variant cultural groups attend the same school may incline 
researchers to view school populations as essentially homoge- 
neous when often they are not. The geographic clustering of 
specific ethnic /cultural groups within urban school populations 
has been a demographic fact for many years. And, in many 
prevention programs, a school-based component forms the core 
of community prevention activities (Pentz, 1986). Thus it is puz- 
zling that in projects with large sample sizes with significant 
multi-ethnic proportions, little is mentioned, in discussions of 
the planning, implementation, and outcome, about ethnic or 
cultural issues (see, for example, Pentz, 1986, on the organization 
of a large prevention program in Kansas City or Ryan and Reyn- 
olds, 1990, on the design of a community action approach to the 
prevention of alcohol problems in San Diego). 

It is hard to reconcile the fact of huge ethnic populations in the 
schools with the abundance of White only or White-dominated 
school samples reported in the prevention research. Schaps et 
al. (1981), having reviewed 127 drug prevention evaluations con- 
ducted between 1968 and 1977, noted that nearly 70% failed 
to specify race or ethnicity, and only three programs served 
populations with more than 50% minority students. In Tobler's 
meta analysis (1986) of 143 adolescent drug and alcohol preven- 
tion programs conducted in the 1980s, only 12.6% of the pro- 
grams were found to serve special, mostly ethnic /racial, popula- 
tions, though these were found to be among the most successful 
in changing alcohol and other drug behavior. 

The manual for a conference at University of California, San 
Diego titled "What Do We Know About School-Based Prevention 
Strategies?" (1990) contained nearly 50 papers reviewing evalu- 
ated alcohol, tobacco, and other drug prevention projects. 
"Here's Looking at You," "DARE," "STAR," and "Project Alert" 
were among the approaches evaluated. Judging by the communi- 
ties in which many of the prevention programs were conducted, 
there had to have been significant proportions of specific ethnic 
groups within the study samples. However, ethnicity was a vari- 
able in the analysis of only two of the evaluations (Elickson and 
Bell, 1990) and was mentioned in only three of the review essays 
(Kumpfer, 1989; Glynn, 1989; Tobler, 1986). Most researchers, 



34 



judging by their analyses, were completely uninterested in the 
possibility of differential outcomes by ethnicity or cultural group. 
Another critical description of school-based alcohol and other 
drug abuse prevention curricula being used across the nation 
during the 1988-89 school year, What Works (Rogers, Howard- 
Pitney and Bruce, 1989), includes a category called "cultural 
sensitivity/ ' Under this category, prevention curricula were rated 
in terms of the degree to which they avoided ethnic stereotypes, 
portrayed a variety of social groups and lifestyles in their materi- 
als, and included suggestions on how to make the materials more 
culturally relevant for special populations. Of the 30 prevention 
programs reviewed, two were rated excellent by these standards, 
nine good, 11 fair, and for seven there was insufficient informa- 
tion. It was unclear whether the raters or the outcome evaluations 
assessed the efficacy of these programs among students of differ- 
ing ethnicity. Again, the possibility of differential effectiveness 
seemed to be a non-issue. This is a significant deficit in prevention 
research, as noted in a recently published critical review of drug 
abuse prevention programs and their evaluations (Gerstein and 
Green, 1993). This review points out that there are "two worlds" 
of drug use: one middle class and White, the other poor and 
mostly ethnic /racial groups, and that substance use patterns and 
the social meanings behind those patterns vary dramatically 
across these two worlds. 

Some Suggestions for Culturally 
Competent School-Based 
Research 

Large-scale school-based prevention programs can be made to 
produce useful data on ethnic subcultures through incorporating 
appropriate demographic variables and including analyses of 
data by ethnicity. Many school districts, particularly those in 
large urban areas, have school populations in which specific 
ethnic subgroups are very well represented, providing an excel- 
lent opportunity for the design of school and community-based 
alcohol and other drug prevention research that carefully 



35 



explores the degree to which culture/ethnicity moderates the 
effects of alcohol and other drug abuse prevention approaches. 
Results from such studies would begin to help us assess whether 
or not ethnic-specific prevention programs are needed for youth 
from various cultural groups and could point the way to unique 
alterations in program design that might enhance the effective- 
ness of a prevention approach when used with a particular group. 
A hint of what might be found in adopting such an approach lies 
in the research of Graham and colleagues (1990), who evaluated 
short-term program effects of a social influence program among 
Los Angeles 7th graders. There was a significant positive pro- 
gram effect for Asian students, no significant positive effects for 
Hispanic and Black students, and no effects for White students. 
Moreover, all positive program effects were among girls, sug- 
gesting that gender role norms interact strongly with ethnic 
group differences. 

The challenge lies in taking such research several steps fur- 
ther by assessing variation in the sociocultural elements that may 
be related to variation in program outcome for different cultural 
groups. The incorporation of culture as a variable in the design 
of prevention research projects from the outset would compel 
consideration of other sensitivity issues: careful and specific des- 
ignation of the cultural groups participating, construction of 
appropriate sampling frames, effective sample recruitment meth- 
ods, language and translation concerns, cross-cultural pretesting 
and norming of program materials and evaluation instruments, 
and methods of involving community members in community- 
wide planning and program implementation. 

Collaboration Between 
Researchers, Local Level Providers, 
and Community Members 

Whether for school or community-based prevention approaches, 
attention needs to be paid to the development of research strate- 
gies that can consider the untidy and relatively uncontrollable 
reality of the informal world outside agencies and institutions 



36 



and can also provide a bridge between these unstructured and 
structured arenas. Such designs will necessarily be the result of 
collaboration between all of the stakeholders: community mem- 
bers, service providers, and researchers. Community members 
can offer essential information about and access to the target 
community. Service providers can supply specific information 
and indepth knowledge about alcohol-related behavior within 
the community. Researchers bring knowledge of research design, 
measurement, and analysis. 

It is very difficult to do community-based research in a cul- 
tural group without getting the cooperation and buy-in of com- 
munity members and leaders (Orlandi, 1986). This may require 
that researchers and service providers work together as a team 
with community members in the formulation of goals for the 
prevention project. It may be that community criteria for the 
success of the intervention will differ from those of the project 
evaluators, and these criteria will need to be considered in the 
evaluation design. Researchers will also need to give assurances 
to the community that the information gathered in the project 
will be disseminated widely and in a form understandable to 
community members (with appropriate concern for issues of 
confidentiality). When trust is established and the sincerity of 
the providers and researchers is plain, there is much that commu- 
nity members can do to enhance researchers' understanding of 
the community and smooth the way for the intervention and 
evaluation. 

Community members can provide an overview of their 
group's history, social and political makeup, and geographical 
layout. They often will have a less specialized and more general 
view of the community's needs and problems than will the pro- 
viders of alcohol or other specific services. Community members 
will often provide entry into private and public settings and 
occasions where drinking behavior takes place, and they can 
offer insider interpretations on the meaning of behavior that 
should be cross-checked among many community persons from 
varying sectors. If language is an issue, they are often invaluable 
in locating interpreters and bilingual people for staffing a survey 
or field team. They are familiar with the local media and can 



37 



point out appropriate print and other media that might cooperate 
in a prevention effort. Importantly, they can warn against obsta- 
cles and barriers to the successful completion of the project. 

The alcohol and other drug-related service-providing agency 
personnel, if available in the target community, can provide 
introductions, sometimes a base from which to operate a research 
effort, and ongoing information on the feasibility of prevention 
programs and evaluation methods as they might be carried out 
in specific target groups within the community. They will be 
among those most interested and, hopefully, benefited by the 
research, and so their stake will be high. 

Information about family dynamics, acculturation concerns, 
and special health issues are among the subjects that can best 
be learned from the service-providing sector of the community. 
Group-relevant theoretical models of prevention research can be 
based in part on the clinical experience of counselors, psycholo- 
gists, social workers, and other service providers working with 
a specific population (Santiestevan and Szapocnik, 1982). 

Collaboration between researchers, community members, 
and providers is often difficult in the initial stages, as each group 
brings to the effort very different perspectives and goals. 
Researchers do not like to hear that the variables making up 
their hypotheses are not salient to the ethnic population in the 
form they may have construed them, or that the information 
that their research seeks to develop is of little interest and utility 
to service providers. Providers, in turn, do not like to be con- 
fronted with the notion that their pet etiological theories must 
be operationalized and subjected to rigorous testing. They may 
be threatened with the notion of an evaluation procedure even 
if it is not evaluating their programs or capabilities. Community 
members want assurance that the programs for which they pro- 
vide input are acceptable and successful in obtaining desired 
outcomes and may be cynical about yet another program or 
approach to a seemingly intractable problem. Nevertheless, pre- 
vention research models hammered out in this type of conceptual 
and action collaboration can build trust and accuracy and are 
likely to hold more promise for ethnic alcohol and other drug 
use prevention research than are models based on researcher 
theorizing alone. 



38 



Conclusion 

This paper began with a recitation of some of the terms associated 
with cultural diversity as they are used in describing service 
provision and evaluation research. It was argued that these terms 
only have relevance if the concept of culture as it relates to 
values, norms, and meanings surrounding behavior are under- 
stood. Numerous ways in which cultural variables affect alcohol 
use and its meaning within cultures were reviewed. Then, first- 
hand experience with research populations during the initial 
stages of theory formulation and research design was recom- 
mended as a corrective to possible ethnocentric assumptions and 
premises that might bias research approaches and interpretation 
of results. Cultural competency in research approaches was 
defined as the active consideration and integration of cultural 
factors in all phases of the research process. The lack of attention 
to cultural variables in school-based prevention and evaluation 
was discussed as illustrative of cultural obliviousness by many 
investigators. Researchers and prevention program planners 
have consistently ignored the vast heterogeneity of school popu- 
lations during a time of increasing cultural differentiation in the 
nation's populace. Finally, the paper presented a rationale for 
research approaches involving collaboration between ethnic 
communities, program providers, and researchers. 

Prevention research is applied research. It points the way to 
effective policy making and action taking. In requiring that ethnic 
minorities and women be included in health-related research 
studies, the National Institutes of Health notes that there are 
clear "scientific and public health reasons" for attention to these 
populations. The mere inclusion of these groups in research 
populations is not scientifically justifiable, however, unless 
research is designed to allow for the unique characteristics and 
needs of these groups, if they do exist, to be revealed. 

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42 



3 



Culturally Sensitive Alcohol 

Prevention Research in 

Ethnic Communities 



James R. Moran 



Introduction 

During a recent interview with an Indian high school student 
from a Southwest tribe, an Anglo investigator in an attempt to 
establish rapport casually asked what class period the student 
was missing to take part in the interview. When the student 
responded that this was biology period, the investigator related 
that biology had not been his favorite course — especially when 
he had to dissect frogs. After a long pause, the student responded, 
"Dissecting frogs is not part of our biology class. It is against 
our religion. They are sacred to us." (Koester, 1993). 

Being sensitive to a person's culture is an important consider- 
ation for those of us who carry out research; and, as the above 
example shows, even the best of intentions is sometimes not 
enough. My purpose in this paper is to examine issues of cultural 
sensitivity in relation to prevention research in ethnic communi- 
ties. I will explore these issues from both individual and institu- 
tional perspectives and will provide guidelines for culturally 
sensitive research. Although specific examples relate to my expe- 
rience and familiarity with American Indian populations, the 
general principles apply to other cultures as well. 



43 



Background 

Room (1990) characterizes much prevention research as an unsta- 
ble mixture of mismatched frames of reference and agendas: 
those of the community members and those of the researchers. 
Community members working with prevention programs are 
immersed in reducing alcohol-related problems in their commu- 
nities. To mobilize support for their efforts, they often believe 
intensely in what they are doing and in the value of their pro- 
grams. On the other hand, researchers must maintain a degree 
of impartiality regarding the programs. The researchers' role is 
often to determine program effectiveness and report the findings, 
positive or negative. Thus, researchers' portrayals of community 
efforts are not always positive and may not sit well with commu- 
nity members. Furthermore, publication of evaluation results 
may bring unwanted and adverse attention to communities. For 
many community members, researchers are an unwanted nui- 
sance, one generally imposed on the community by outside fund- 
ing sources. Evaluation is often viewed as done not "for" the 
community, but rather "to" the community. 

These issues are likely to apply to most communities; how- 
ever, they are particularly important when research is focused 
on prevention efforts taking place in ethnic communities. A major 
reason for this is that besides the ordinary insider-outsider con- 
cerns, research dealing with these communities requires under- 
standing of and sensitivity to the particular culture. An important 
layer of this understanding is to see the historical nature of 
the relationship between the dominant culture and the target 
community. For example, in the case of American Indians there 
exists a 500-year history of oppression and domination — at times 
approaching genocide. Similar histories are present for other 
groups, so that many ethnic communities have a historical dis- 
trust of the dominant society (Lockart, 1981). When the research 
is seen as imposed on prevention programs from outside the 
community, this distrust is likely to escalate and form a signifi- 
cant barrier. In this situation the evaluation is not likely to pro- 
duce useful results for either the target community or the larger 
society. To overcome this we must find ways to make research 



44 



and evaluation relevant to communities. One way to approach 
this is to be sensitive to cultural differences and to treat such 
differences with respect. To the extent that we fail to do this, at 
best we will have little constructive impact and at worst we will 
produce negative consequences. Two brief examples may help 
clarify this issue. 

Barrow Alaska Study 

In the summer of 1979, the Department of Public Safety in Bar- 
row, Alaska, began a research study to obtain data that could 
be used to establish more effective prevention programs for the 
Barrow community. A key part of this study was a survey of 
native persons in the Inupiat community of Barrow to examine 
drinking behavior and attitudes about alcohol use (Foulks, 1989). n 

A consulting firm in Seattle was hired to conduct the research. 
This firm subcontracted with an established research center in j 

Philadelphia to carry out the community survey. A steering com- b 

mittee consisting of local Inupiat leaders and a technical advisory 
group consisting of mostly non-native professionals from Barrow ; 

agencies were formed to provide input into the research process. 

The community survey revealed serious and substantial 
abuses of alcohol including excessive drinking, family problems, 
fighting, and frequent blackouts among many respondents. 
However, for this paper, it is not the results of the study that 
are important. It is the research process and particularly the 
manner in which the results were reported that provide guidance 
about cultural sensitivity. 

After reviewing a draft of the study report, the technical 
advisory committee said that it was difficult to read, verbose, 
and ambiguous. In addition, the committee indicated that the 
draft report imposed outside standards on the native society 
without reflecting attitudes and values of the community (Foulks, 
1989). In response, a series of meetings between the research 
team and the technical advisory group took place over a period 
of several months to resolve these issues. The research team also 
presented the results to the steering committee and scheduled 
a town meeting to present the results to the community. 



45 



This process appears reasonable and sensitive to community 
concerns; however, positive effects of the study were frustrated 
by the next occurrence. The Seattle consulting firm and the Bar- 
row Department of Public Safety decided to release the report 
to the press prior to the town meeting to shock the Inupiat into 
action to control the alcohol problem (Foulks, 1989). The press 
conference took place in Philadelphia, and the news release was 
picked up by the national wire services. The study results 
received widespread and sensational coverage, thus furthering 
the stereotype of the drunken Alaska Native. However, rather 
than shocking the community into action, the public release of 
the study results angered the community. The public exposure 
brought shame on the community and a backlash of resentment 
and defensiveness from many community members. The 
research team belatedly recognized the mistake of the premature 
and public release of the study results; however, the Barrow 
alcohol study remains an illustration of a lost opportunity for 
research to contribute to a community's well-being. 

Blue Bay Study 

A second example concerns the Blue Bay Project, an Office for 
Substance Abuse Prevention (OSAP) funded program located 
on the Flathead reservation in Montana. Developed by the Tribal 
Substance Abuse Program with the assistance of the Cultural 
Committees from both the Salish and Kootenai Tribes, the pro- 
gram incorporates many components focused on strategies for 
reducing or preventing alcohol use on the reservation (Whiting- 
Sorrell, 1991). 

Two key points concerning the annual OSAP evaluations of 
Blue Bay are important for this paper. First, much of the evalua- 
tion work has been contracted to a university-based Indian 
researcher who had extensive experience in both alcohol-related 
research and in evaluation involving several different tribes. 
While not a member of the Salish or Kootenai Tribes, this 
researcher was aware of relevant cultural issues. Second, the 
evaluations had been carried out by this researcher over a period 
of several years, thus enabling the establishment of a relationship 
with the community and program personnel. 



46 



Lessons from These Community Studies 

The Barrow study and the Blue Bay evaluations represent alterna- 
tives for approaching research in ethnic communities. The Bar- 
row research used mainly non-native outsiders in a one-shot 
study that occurred over a brief time span. No ongoing relation- 
ship was developed, and it appears that what trust was estab- 
lished was destroyed by the premature public release of the 
study results. On the other hand, the Blue Bay research employed 
an American Indian as the lead researcher and the research 
was conducted at intervals over several years, thus establishing 
legitimacy and decreasing the insider-outsider gap. In short, the 
Barrow study represents a lack of cultural sensitivity while the 
Blue Bay evaluations demonstrate sensitivity to cultural issues. 
These examples illustrate that to accomplish culturally sensi- 
tive research, two separate but related issues must be addressed. 
First, we as individual researchers need to be sensitive to cultural 
differences and treat such differences with respect. Second, the 
research enterprise, including among other issues training pro- 
grams and funding organizations, must also make modifications 
to deal with cultural sensitivity. 

Individual Factors 

Cultural Competency 

At the individual level much work has been done concerning 
the overall issue of cultural diversity and more specifically the 
issue of cultural sensitivity. Tello (1985), Cross (1988), Cardenas 
(1989), and Orlandi (1992) refer to this as cultural competency. 
While varying slightly, these authors view competency as occur- 
ring in stages, with simple awareness of cultural differences 
being a necessary first step. The second stage is self-assessment, 
that is, the awareness of one's own cultural values. It is thought 
that people must understand their own culture (i.e., recognize 
that they have a cultural lens) before they can be sensitive to other 
cultures. The third stage is an understanding of the dynamics that 
may occur when members of different cultures interact. These 
three steps enable individuals to adapt to diversity and to adjust 



47 



professional skills to fit within the cultural context of the ethnic 
community. Green (1982) clarifies this process by pointing out 
that to be culturally competent means to conduct one's profes- 
sional work in a way that is congruent with the behaviors and 
expectations that members of a cultural group recognize as 
appropriate among themselves. He states that it does not mean 
that researchers can conduct themselves "as though" they are a 
member of the group. Rather, they can engage the community 
on something other than their own terms and demonstrate accep- 
tance of cultural differences openly, without condescension. 

The Meaning of Culture, Cultural Change, and Cultural 
Sensitivity. To expand upon this issue, the term culture must 
be given substance. Lum (1986) summarizes many ideas concern- 
ing culture. He indicates that culture deals with the social heri- 
tage of humans. Culture is the way of life of a society. The 
prescribed ways of behaving, beliefs, values, and skills are vari- 
ous aspects of culture. It is the sum total of life patterns passed 
on from one generation to the next within a group of people. 
Culture is a code that guides interpretation of behavior. Orlandi 
(1992, p. vi) in a recent OSAP monograph puts it this way, 
"Culture is the shared values, norms, traditions, customs, arts, 
history, folklore, and institutions of a group of people." 

From the above it is clear that culture is not static but is 
constantly being altered. Indeed, cultures can be viewed as living, 
evolving systems where over time some cultural traits remain, 
some change, and others are discarded (Attneave, 1989). A com- 
mon, but limited, view of cultural change is that it occurs along 
a single continuum from "traditional" to "modern." Drawing 
attention to this perspective is important because it is both com- 
mon and it can lead to the devaluing of the culture of the people 
under study (Beauvais, 1989). Inherent in this approach to cul- 
tural change is the idea that people move from the old to the 
new; and, while in transit, they are confused, experiencing stress, 
and in general are not able to function competently. Something 
of the old is lost when one embraces the new. These themes of 
loss, confusion, and stress emphasize the negative aspects of 
cultural change and represent a limited view. This approach can 
contribute to a lack of cultural sensitivity. 



48 



An alternative to this linear view of cultural change is the 
concept of biculturalism. Biculturalism is the ability to function 
effectively in the mainstream culture and yet maintain positive 
and significant cultural connections to the ethnic community. 
Oetting (1989) refers to this approach as orthogonal ethnic iden- 
tity. This approach draws attention to the idea that people are 
capable of identifying independently with more than one culture. 
McFee (1968) describes how some Indians in his research shifted 
their frame of reference when interacting with Whites and then 
shifted back again when dealing with members of their Blackfeet 
community. He formed the metaphor of "ISO /© man." While 
possibly mystifying the process, this metaphor points out that, 
for his respondents, cultural change was not a journey of loss 
but rather one of gain. The bicultural approach introduces the 
possibility of increased cultural sensitivity because it allows 
equal treatment and co-existence of cultures rather than requiring 
the movement from "traditional" to "modern." 

To be culturally sensitive, a researcher needs to gain an 
understanding of the meaning of the institutions, values, reli- 
gious ideals, habits of thinking, artistic expressions, and patterns 
of social and interpersonal relationships that influence the lives 
of the members of the community in which the research is to 
take place. Clearly this is not a simple task. How well non- 
members of a culture can actually accomplish this is certainly 
questionable. However, the alternative of ignoring culture in 
working with ethnic populations relegates the research endeavor 
to one of little importance to these communities. 

Typology of Values. A useful starting point in thinking 
about cultural sensitivity is to focus on values. Some authors 
have developed typologies that compare dominant cultural and 
other, primarily ethnic cultural values. Randall-David (1989) 
compares common values of "Anglo and Other Ethnocultural 
Groups." For example, she shows that Anglos value mastery 
over nature, doing activity, and individualism while other ethno- 
cultural groups value harmony with nature, being, and group 
welfare. It is important to note that approaches such as this most 
often treat culture as a dichotomy, comparing Anglo values to the 
values of all other cultural groups. Although there may indeed be 



49 



many similarities between broad cultural groups, these typolog- 
ies carry the risk of lumping together all Anglo and all non- 
Anglo cultures and attempting to treat them as if there are only 
two large cultural groups. The limitation of this is apparent when 
one considers the multitude of cultures within even one of the 
ethnic populations. For example, the Hispanic /Latino culture 
consists of people from a wide range of geographical and national 
backgrounds. The same can be said of the Asian and African 
American populations. Even the American Indian population, 
although often thought of as one general culture, consists of 
over 512 federally recognized and another 365 state-recognized 
groups (Fleming, 1992). 

This approach to understanding cultures also carries with it 
the danger of the ecological fallacy. That is, what may be true 
for the larger group may not be true for the individual group 
member. Even if precise values and cultural traits can be specified 
for each division and subdivision of an ethnic group, they 
may not be applicable to individual members of the group. In 
essence, the risk inherent in the use of frameworks that specify 
particular cultural values /traits is that stereotypes may be 
formed which are then applied to all members of the culture 
under consideration. 

So why use these frameworks at all? Taking these cautions 
and limitations into account, this dichotomous approach remains 
useful as an overview in helping to sort out possible areas of 
cultural difference. It draws attention to the idea of differences 
and gives direction to researchers in their quest to understand 
the meaning of culture for themselves and for their target popula- 
tions. Use of such frameworks can assist researchers in working 
through the first two steps of cultural competency, those of 
acquiring an awareness of cultural differences and becoming 
aware of one's own culture. In other words, this approach is a 
reasonable starting point for more indepth inquiry into the issue 
of cultural sensitivity. 

After this starting point of examining differences in cultural 
values, what comes next? Given the range of cultures that exist 
and the amount and kind of knowledge that is necessary to carry 
out research in a way that is compatible with the culture of the 



50 






study population, how can researchers attain an advanced level 
of cultural sensitivity? 

Get Involved with the Community. The simple answer 
is that the researchers must become involved with the target 
community in a way that allows for the acquisition of meaningful 
cultural knowledge. Since the culture of each ethnic group and 
perhaps each community varies, there is no substitute for direct 
and extended involvement with the community of interest. This 
involvement does not occur in a vacuum; rather, it happens as 
part of the research process. Frameworks such as that presented 
by Randall-David (1989) can start the process of acquiring an 
awareness of cultural issues that facilitates entry into ethnic com- 
munities, while involvement with the community is necessary 
to enhance cultural sensitivity. 

Institutional Factors L 

r ! 
But how likely is it that individual researchers, even given a 

strong desire to attain culturally sensitive research skills, will 

have the time and resources to accomplish the process described 

above? This is where the larger research undertakings of training 

and funding come into play. Once new researchers complete 

their formal education and enter the field, it will be difficult for 

them to devote the resources necessary to focus on cultural issues. 

Research Training 

The initial process of acquiring an awareness of cultural issues 
must be incorporated into the basic training of researchers who 
aspire to conduct work in ethnic communities. University-based 
programs need to include an examination of cultural issues in 
programs utilized to train researchers. It is probably unrealistic 
to expect coverage of cultural material in all research courses; 
however, the alternative of no coverage is not acceptable. Intro- 
duction research method courses could be modified to incorpo- 
rate information on alternative world views, and frameworks 
comparing different value structures could be discussed with 
special focus on the implications for cross-cultural research. In 
addition, a particularly promising alternative would be the inclu- 



51 



sion of some type of cross-cultural research internship. By them- 
selves these steps would not produce culturally sensitive 
researchers; however, this approach to training would be an 
important first step. The challenge here is to design programs 
in a way that incorporates in-depth coverage of cultural issues, 
while not taking away from the research methods and statistical 
related material that are necessary to produce competent 
researchers. 

Research Funding 

At the funding stage, individual researchers rely primarily on 
government agencies and foundations for resources to carry out 
research projects. Research grants focused on ethnic communities 
should support the extra time and energy necessary to carry out 
appropriate cross-cultural work. Besides technical merit, propos- 
als that involve research with ethnic groups should be evaluated 
on the cross-cultural experience of the research team, the demon- 
stration of knowledge specific to the target culture, the use of 
culturally specific interventions /instrumentation, and the utili- 
zation of cultural consultants. If an important project is proposed 
that lacks some of these factors, funding should be set at a level 
that provides adequate resources and time to address these 
issues. When funding sources deal with cross-cultural research 
in this manner, culturally sensitive research will become a possi- 
bility. 

Guidelines for Action 

Attention to the individual and structural issues described above 
are important in the end to producing more culturally sensitive 
research. In addition, there are culturally sensitive guidelines or 
operating principles that are currently available. Some of these 
are as follows: (1) the community's ideas and the researcher's 
ideas are both important — the definition of problems and the 
goals of the research should involve the community in a mean- 
ingful way; (2) community leaders may not know what the com- 
munity's needs are — a needs assessment should be conducted; 
and (3) community members may not understand the "research 



52 



culture" or the needs of the research process — explanation of 
these issues will need to take place, and it is essential that it be 
accomplished respectfully. 

Obtaining Community Support 

In conducting research in American Indian communities, a first 
step is to describe the intent, nature, and benefits of a possible 
project before the governing body (Beauvais & Trimble, 1992). 
On reservations, identification of the governing body is clear- 
cut and would ordinarily be the Tribal Council. Urban Indian 
communities do not have a governing body; however, for 
research purposes, a parallel step might mean meeting with a 
group composed of representatives from the major Indian orga- 
nizations. In addition, a community meeting open to all Indian 
people could be utilized to explain the purpose, costs, and bene- 
fits of the research. It is important to note that the purpose of 
such meetings is both to show respect for the community by 
informing them about the proposed research and, equally as 
important, to obtain feedback from the community. 

Research with other ethnic communities would likely follow 
this approach of meeting with representatives of organizations 
and conducting community meetings. The point of this process 
is that an important part of being culturally sensitive is to have 
the sanction of the community. Without it, whether formal or 
informal, researchers will always be seen as outsiders and hence 
be frustrated in further attempts to establish credibility. 

One example is a research project I conducted in an urban 
Indian community. The purpose was to examine barriers encoun- 
tered by American Indians in their use of human services agen- 
cies. In designing the study, I proposed that a sample of Indian 
people be interviewed concerning their experiences in attempt- 
ing to obtain services. Following the procedures outlined above, 
I presented this idea to a group of Indian people, including 
several formal and informal leaders from the community. The 
response was that "Indians have been studied enough! If you 
want to find out about agency barriers, go talk to the agencies." 
Thus, sanction for the original proposal was not obtained from 
this community group. I followed their advice and modified the 



53 



study to begin by interviewing a sample of agencies used as 
referral sources by the major Indian community agency. Endorse- 
ment for this new approach was obtained from the community 
group. The project was successful, and eventually many Indian 
people provided input into the study. The key to carrying out 
this research was obtaining community support by asking for 
and accepting guidance from the community. 

Involving the Community 

In addition to obtaining community support, culturally sensitive 
research involves the community in the actual research process 
from start to finish (Davidson, 1988). The research team should 
include the technical researchers, a broadly constituted steering 
committee, and local research colleagues (Mohatt, 1989). To every 
extent possible, ethnic community members should be employed 
as part of the research team. This team should then meet as a 
group throughout the process of the research to determine and 
monitor the specifics of implementation, explanations to the com- 
munity, and reporting of results. 

While not addressing all ethnic communities, Shore (1989) 
in his ' 'Essentials for Psychiatric Research with American Indians 
and Alaska Natives" outlined many steps necessary for cultur- 
ally sensitive work in these communities. The elements of his 
schema as modified to reflect general research with all ethnic 
cultures are: 

1. Planning should begin with collaboration between the 
researcher and the community. 

2. The focus of the research should be compatible with local pri- 
orities. 

3. The research design and the selection of a particular methodol- 
ogy should consider the relevance of the outcome for use by 
the community. 

4. The methodology should be realistically conceived and lim- 
ited in its focus and goals. It should be a practical method 
for field application in a transcultural setting. 

5. The research should be implemented in a local community 
partnership with an attempt to employ community members 
as staff whenever possible. 



54 



6. An agreement should involve sharing the research findings 
with the local community in a way that maximizes relevance 
for program planning. 

7. Human rights must be protected, (i.e., informed consents 
used) 

8. Community confidentiality must be protected. 

Conclusion 

It is through conscious and sustained attention to issues of cul- 
tural sensitivity that we can serve ethnic communities. We must 
first seek to understand the historical and contemporary nature 
of the cultures with whom we work. With this initial cultural 
understanding, we can then concentrate on forming research 
partnerships with ethnic communities. It is this commitment to 
working in partnership that is the measure of culturally sensitive t 

research. The strategy presented in this paper — that is, focusing 
on individual and institutional factors that lead to a research j2n 

partnership — creates the possibility that we as researchers can 
contribute lasting value to ethnic communities. 



References 



Attneave, C.L. Who has the responsibility? An evolving model to resolve ethical 
problems in intercultural research. American Indian and Alaska Native Mental 
Health Research, 2(3): 18-24, 1989. 

Beauvais, F. Limited notions of culture ensure research failure. American Indian 
and Alaska Native Mental Health Research, 2(3):25-28, 1989. 

Beauvais, F., and Trimble, J.E. The role of the researcher in evaluating American 
Indian drug abuse prevention programs. In: Orlandi, M, ed. Cultural Compe- 
tence for Evaluators: A Guide for Alcohol and Other Drug Abuse Prevention 
Practitioners Working with Ethnic/Racial Communities, Cultural Competence 
Series 1, OSAP, Rockville, MD, 1992, pp. 173-201. 

Cardenas, P. Culture and cultural competency: Youth focused prevention and inter- 
vention. Monograph of the Colorado State Alcohol and Drug Division. Den- 
ver, CO., 1989. 

Cross, T. Services to minority populations: Cultural competence continuum. 
Focal Point, 3(l):l-4, 1988. 

Davidson, M.E. Advocacy research: Social context of social research. In: Jacobs, 
C. & Bowles, D., eds. Ethnicity and Race: Critical Concepts in Social Work, 
National Association of Social Workers. Silver Spring, MD, 1988. 









55 



Fleming, CM. American Indians and Alaska Natives: Changing societies past 
and present. In: Orlandi, M., ed. Cultural Competence for Evaluators: A Guide 
for Alcohol and Other Drug Abuse Prevention Practitioners Working with Ethnic/ 
Racial Communities, Cultural Competence Series 1, OSAP. Rockville, MD, 
1992. 

Foulks, E.F. Misalliances in the Barrow alcohol study. American Indian and 
Alaska Native Mental Health Research, 2(3):7-17, 1989. 

Green, J.W. Cultural Awareness in the Human Services. Englewood Cliffs, NJ: 
Prentice-Hall, 1982. 

Koester, S. Personal communication, March 12, 1993. 

Lockart, B. Historical distrust and the counseling of American Indians and 
Alaska Natives. White Cloud Journal, 2(3):31-34, 1981. 

Lum, D. Social Work Practice and People of Color. Monterey, CA.: Brooks/Cole 
Publishing Company, 1986. 

McFee, M. The 150% man, a product of Blackfeet acculturation. American 
Anthropologist, 70:1096-1103, 1968. 

Mohatt, G.V. The community as informant or collaborator? American Indian 
and Alaska Native Mental Health Research, 2(3):64-70, 1989. 

Oetting, E.R. Orthogonal cultural identification: Theoretical links between cultural 
identification and substance use. Unpublished manuscript. Colorado State Uni- 
versity, Tri-Ethnic Center for Prevention Research, 1989. 

Orlandi, M.A. Defining cultural competence: An organizing framework. In: 
Orlandi, M., ed. Cultural Competence for Evaluators: A Guide for Alcohol and 
Other Drug Abuse Prevention Practitioners Working with Ethnic/Racial Commu- 
nities, Cultural Competence Series 1, OSAP, Rockville, MD, 1992. 

Randall-David, E. Strategies for Working With Culturally Diverse Communities 
and Clients. Washington, D.C.: Association for the Care of Children's 
Health, 1989. 

Room, R. Community action and alcohol problems: The demonstration project 
as an unstable mixture. In: Giesbrecht, N., et al., eds. Research, Action, and 
the Community, Monograph 4, Rockville, MD, 1990. 

Shore, J.H. Transcultural research run amok or Arctic hysteria? American Indian 
and Alaska Native Mental Health Research, 2(3):46-50, 1989. 

Tello, J. Developing cultural competence: Awareness, Sensitivity, Integration, and 
Competence. Unpublished manuscript, 1985. 

Whiting-Sorrell, A. Personal communication, July 17, 1991. 



56 



4 

The Relevancy of Cultural 

Sensitivity in Alcohol 

Prevention Research in 

Ethnic/Racial Communities 

Robert G. Robinson 



Introduction 

Drs. Jean Gilbert and James Moran have very ably provided a 
framework for understanding the complex meaning of cultural 
sensitivity. In addition, they have also made clear that a prerequi- 
site for cultural sensitivity is a basic respect for the social context 
of defined populations. Culture expresses the reality of groups. 
It is learned through processes of language and interactions and 
reinforced through socialization. Culture is dynamic, ever chang- 
ing, ever responsive, and, most important, is continuously integ- 
rative and uniquely expressive of itself. Similar to water which 
constantly seeks its own level, the culture of a people transforms 
and reshapes itself, in the words of Dr. Gilbert, "by cumulative 
adaption to changed circumstances." Culture expresses the way 
of life of a people and mirrors its norms, beliefs, values, and 
skills. It acts, according to Dr. Moran, as "a code that guides the 
interpretation of behavior." In essence, culture is a lens through 
which reality is experienced and perceived. We are reminded 
that all reality is socially constructed, and that there are as many 
realities as there are historically bound groups. 



6i 



fc; 



57 



The historical nature of culture could have received more 
attention. The term "historically bound groups" suggests that 
there are as many cultures in the world as there are such groups. 
The term "bound" does not imply bondage or entrapment. 
Indeed, culture can be liberating as well as stifling to the human 
spirit. Historically bound means simply that each culture is deter- 
mined by its unique historical path. It cannot be defined indepen- 
dently of that path, and therefore it cannot be understood without 
appreciating its particular historical context. Each author 
addresses in depth the need for cultural sensitivity if researchers 
are to do good research. Each author explains how difficult is 
the task to be culturally sensitive. However, part of that difficulty 
is the refusal to come to terms with history. It is a difficulty that 
the authors do not fully address; despite their able response to 
the need for researchers to respect and understand the relevance 
of the unique historical underpinnings of a group's current social 
reality. It may be a task too comprehensive for the modern 
researcher. 

History is particularly important when the relationship 
between the group represented by the researcher is not on an 
equal footing with the group being researched. This is critical 
when the historical context of the group being researched is 
intimately entwined with the group of the researcher. For exam- 
ple, it is often said that a cultural characteristic of the people of 
the United States is that they are ahistorical. In other words, the 
events of today can be explained by the sum total of four, eight, 
or 20 years. Indeed, the numerical unit chosen may be more a 
function of one's political party than of historical awareness. 
Thus, we can be subjected to such simplistic analyses as that the 
anger that followed the Rodney King verdict is rooted in late 
20th century social policy rather than the context of slavery and 
racism. This exemplifies an ahistorical analysis. 

It is typically impossible, or at least relentlessly difficult, for 
the average White American to focus on the historical legacy of 
slavery. Yet, if an in-depth discussion with an African American 
is pursued, he or she will demonstrate an understanding of this 
legacy. If you engage an American Indian, the discussion will 
lead to the topic of their attempted genocide. Discussions with 



58 



Chicanos may very well lead to the topic of the United States 
appropriation of Mexican land. The fact that for other groups 
the historical path is clouded because we have not been taught 
the truth does not invalidate the importance of understanding 
history. 

Researchers who are insufficiently self-critical of their own 
lack of historical knowledge of a people are particularly at risk 
for being insensitive. Indeed, they will underestimate the com- 
munity, and there will certainly be a representative present who 
has a grasp of the historical legacy. Appreciation of historical 
context by researchers will be relevant even in circumstances 
when the research question being studied is not firmly rooted 
in the historical context of the community. The importance of 
cultural sensitivity is only partially determined by the nature of 
the problem being studied. Its importance also derives from the 
fact that cultural sensitivity is heightened by the awareness that 
history shapes the differences researchers seek to analyze in 
explaining cause and effect. Regardless of the problem, "the level 
of appreciation" for historical context will predict the research- 
er's capacity to be culturally sensitive. 

One barrier to cultural sensitivity is the difficulty of overcom- 
ing the roles of oppressor and oppressed. The authors pose other 
barriers. Certainly major barriers are the abstract nature of the 
elements of culture and their immense variability across cultural 
groups. Unlike material manifestations of culture — such as dress, 
food, and levels of technology — values, beliefs, and perceptions 
are not visible, more precisely, they are abstractions. Indeed, 
these abstractions are the primary elements that shape the norma- 
tive context of behavior (i.e., alcohol use or abuse). If these 
abstract elements cannot be experienced, then they cannot be 
integrated into the conceptual framework of the study. Or, if 
they are incompletely understood, they are poorly used in the 
research process. Again, the danger emerges when the researcher 
is ignorant of his/her limitations. Without self-criticism there is 
no corrective process. Without humility there is no true respect 
for the need to be self-critical. 

Lack of cultural sensitivity is further exacerbated by diver- 
gent agendas of the researcher and the community. Although 



59 






neither exists in its ideal form, the researcher maintains an objec- 
tive relationship to the community and the community is 
absorbed in the subjective experience of the phenomena being 
researched. The needs of both the researcher and the community 
are different, the stakes of each are different, and the rewards, 
while not mutually exclusive, are certainly not interdependent. 
Dr. Moran reminds us that this is particularly problematic in 
ethnic /racial communities, given the historical context of distrust 
and alienation directed to persons perceived as outsiders. It is 
likely that researchers who are part of the communities being 
researched will experience the same rewards shared by the com- 
munity. When this occurs, interdependency is enhanced. This 
shared experience may also be experienced by outside research- 
ers. If researchers, regardless of origin, could objectify this experi- 
ence, then they would have a measure of cultural sensitivity. 

How then are these barriers overcome? How does the 
researcher achieve cultural sensitivity? First, there is the realiza- 
tion that culturally sensitive research is a process, not a product. 
It is the way one engages the community. It is the rules or 
principles governing the research process that determine the 
degree of cultural sensitivity. Dr. Gilbert quotes Rogler and states 
it is "a continuing and open-ended series of substantive and 
methodological insertions and adaption designed to mesh the 
process of inquiry with the cultural characteristics of the group 
being studied/ 7 In more practical terms, Dr. Moran suggests that 
the researcher must become involved with the community in a 
direct and extended manner, involve the community and ideally 
allow the research goals to evolve from the community, imple- 
ment a needs assessment, and educate the community regarding 
the characteristics and perhaps even the requirements of the 
research process. Other suggestions are to hold community meet- 
ings and follow their advice, involve the community from start 
to finish, and employ members of the community as part of 
the team. 

Dr. Moran poses a concept of cultural competency. This con- 
cept is very similar to the steps, suggested by Dr. Gilbert, to be 
taken by the researcher on the path to cultural sensitivity. The 
researcher must be aware of cultural differences or at least admit 



60 






how little he/she knows. The researcher must be open to self- 
assessment or at least an examination of his/her assumptions 
of the culture with those of the group being studied. Indeed, 
direct immersion in the community is again advised as the best 
corrective for testing one's assumptions. 

The final threshold of cultural competency is for researchers 
to adjust their professional skills to fit the cultural context of 
the ethnic /racial community or, ideally, conduct themselves as 
though they were a member of the community. The research 
itself must rely on group-specific baseline data, target the infor- 
mal sector of the community where most of the targeted behavior 
occurs, and relate to the influence and power structures in the 
community, particularly when mobilization for policy-related 
changes is needed. The result of these changes and adaptations 
is research that will be more relevant to the community, more 
descriptive of cultural differences, and more likely to explain 
program effectiveness across cultural groups or suggest when 
specific tailoring of programs is needed. x ? 

Summary Comments 

The following are summary comments of selected analyses posed 
by the authors, as well as independent assessments. 

1. Each author discusses in depth the need for researchers to 
involve themselves intimately with the community. However, 
the amount of time being provided to researchers to do their 
work is being shortened, not lengthened. Where will the time 
come from for all of this mtimacy and direct immersion? The 
current environment may very well result in an increase in 
research that is less culturally sensitive. 

2. Biculturalism, or the ability to function adequately in both 
worlds, is viewed as a positive extension of acculturation. The 
example in Dr. Moran's text is of an American Indian who is 
described as "150% man." The author admits that this concept 
potentially mystifies the process of becoming bicultural. One 
is reminded of the descriptions used for successful African 
Americans who were considered "exceptional/ 7 Perhaps a 
more "sensitive" appraisal views this person as just a man, 



61 






and views those who are unable to achieve similar levels of 
sensitivity as deficient and in need of improvement. Admit- 
tedly, Dr. Moran is using the concept to suggest that progress 
is not linear but a synthesis of multiple experiences, including 
divergent cultures. 

3. There is a distinction between researchers who lack cultural 
sensitivity in contrast to a research environment that is inher- 
ently insensitive because it reflects a particular, usually a dom- 
inant, culture. The solution to the former is that we need 
better researchers. The solution to the latter is that we need 
structural changes in the way researchers are educated, 
research priorities defined, and research projects funded. The 
recommendations were necessarily prescriptive and lacked 
power because they were not rooted in empowerment strate- 
gies that might lead to real change. This is less a criticism of 
the authors than a suggestion for the work that needs to occur. 

4. The inherent humanism in cultural sensitivity should not be 
used to disguise the need to address issues of affirmative 
action, or prescribe a research agenda that is responsive to 
the critical need for more researchers of color in principal 
investigator and related leadership roles. 

5. Little attention was given to research goals that targeted struc- 
tural or policy-related changes regarding alcohol use or abuse. 
Prevention research was often defined as targeting behavioral 
change. The evaluation goal was to determine effectiveness 
in achieving behavioral change. Ironically, cultural sensitivity 
suggests, in communities of color, that researchers target the 
environment rather than the individual. If outcome priorities 
were reordered, then other criteria for evaluating the efficacy 
of research projects would need to be established (i.e., capacity 
development of organizations, increased awareness of gate- 
keepers, cross-substance abuse coalitions, legislative initia- 
tives). The communities we are discussing at this workshop 
require more than sensitivity; they require advocacy. 

6. Research that targets communities of color must include com- 
munity development components. The criteria for evaluating 
research should depend on more than rigor as defined by 
sample size, control groups, or tests of significance. Other 



62 



criteria are how effectively communities can initiate, develop, 
and evaluate related programs after the research. Another 
criterion is whether researchers of the community were 
trained during the process. 

Two notes of caution are offered. First, there is the danger 
in viewing change as a zero-sum game. Including community 
development criteria is seen as a loss for other research priorities. 
Second, the funding criteria may be altered and add to the diffi- 
culty of getting research funded, or at least change the rules in 
a way that benefits competitors. The first concern should be 
modified by appreciating that no one paradigm offers a total 
solution. It is critical to make room for alternative models to help 
achieve a broader, hopefully improved, assessment of complex 
problems. Regarding the second concern, if criteria are presented 
to benefit other researchers such as African American, American § 

Indian, Hispanic, or Asian researchers, it could be cost effective ij v. 

when they provide assessments that result in better interven- 
tions. 



The problem of communities that perceive evaluation as an 



assistance by which the program is improved rather than 
only measured. Of course, this will depend on the stage of 
the program and whether it has ever been evaluated. More 
important, it suggests that the research environment at large 
can be measured by how much of its resources targets "pure" 
evaluation vs. evaluation that is instructive and corrective. 
This too can be built into the criteria for funding. 

8. Some attention should be given to the categorical nature of 
alcohol- and drug-related research. From the perspective of 
community empowerment, the targeting of separate social 
problems, separate coalitions, and separate components of 
community infrastructure contributes to fragmentation. This 
is inherently disempowering and contrary to principles of 
community development. 

9. The solutions suggested for cultural sensitivity approximate 
recipes for behavior changes. They each require that the 



invasion can be solved if evaluation is implemented accord- 
ing to principles of cooperation, collaboration, and technical 



63 



researcher make a credible investment in the time he/she 
spends with the community under investigation. In fact, most 
successful researchers are engaged in multiple projects with 
little time to spend in the field. They work through subordi- 
nates who are themselves overworked. Unless solutions are 
posed that will address the research environment, then 
researchers will have little inspiration to change behavior. 

10. Culturally sensitive research will be best done by representa- 
tives of the culture. Unless affirmative action is supported 
in educational programs, NIH, and related research centers, 
then the goal to increase the amount of culturally sensitive 
research will only be minimally met. This principle does not 
suggest that only researchers of a community should do the 
research. Rather, the statement describes a basic correlation. 
An increase in culturally sensitive research will occur accord- 
ing to the number of researchers from the community 
engaged in the research. Ideally, they should be the principal 
investigators of the projects. 

11. Community development is a criterion that can potentially 
affect several research-related outcomes. (1) It will influence 
the relationship between the research team and the commu- 
nity. (2) It will influence the makeup of the research team. 
(3) It will influence measures of efficacy and effectiveness 
in evaluating the results of the research. (4) If community 
development is also perceived as a concept that influences 
the development of researchers as well as communities, it 
will impact research priorities. For example, material and 
program development-related research is more conducive 
to developing and preparing emergent researchers (presum- 
ably from communities of color) in their early careers. It is 
not realistic to expect an increase in researchers from commu- 
nities of color if funding primarily targets large trials or 
demonstration projects that typically require experienced 
leadership (presumably from the dominant community). (5) 
Another benefit of directing funding to "early phase" 
research is that the qualitative methods usually emphasized 
in these designs and protocols facilitate outreach and devel- 
opment of community leadership (i.e., focus groups can be 



64 



used to identify lay leadership). This is precisely the infra- 
structure needed when community-based demonstration 
projects are implemented. Finally, what is suggested is that 
the ultimate effectiveness of intervention research will be 
enhanced if community development is integrated into each 
research phase. 



U 






65 



Part III 

Conceptual and 

Methodological Issues in 

Community-Based 

Prevention Research 



I 



5 

Alternative Models of 

Community Prevention 

Research in Ethnically and 

Culturally Diverse 

Communities 

Mary Ann Pentz 



d 



Introduction 

Several national surveys have shown that, overall, adult and 
adolescent drug use is declining in the United States (Johnston, et 
al., 1989; Goldstein and Kalant, 1990). There are some exceptions. 
Most notably, the prevalence rate of daily crack use among adults 
has not declined; nor has the prevalence rate of heavy alcohol 
use among adolescents and college students declined (Johnston, 
et al., 1989; Goldstein and Kalant, 1990). Problems associated 
with alcohol and other drug abuse, particularly accidental and 
violent deaths, and crime, have also not declined (Goldstein and 
Kalant, 1990). 

Changes in drug use have been attributed to national mass 
media attention to the drug abuse problem, establishment of 
school prevention programs, and, most recently, efforts to orga- 
nize communities for alcohol and other drug abuse prevention 
(Pentz and Valente, 1993). Systematic evaluation of the indepen- 
dent effects of each on community drug use is difficult, since 



69 



all three "movements" have occurred in rapid succession or 
simultaneously since the mid-1980's. However, quasi-experi- 
mental comparisons of the outcomes rendered from school-based 
prevention programs (the most common interventions available 
for drug abuse prevention) with community -based heart disease 
and drug abuse prevention programs suggest that the latter may 
produce relatively larger and longer lasting declines in drug use 
(Kottke, et al., 1985; Vartiaian, et al., 1990; Pentz, in press). One 
obvious explanation for the difference is a dose-response effect: 
community interventions typically expose individuals to more 
prevention program channels and messages more of the time 
compared to limited, single-channel programs such as school 
educational programs. However, community interventions are 
not simply a compilation of multiple program components. 
While difficult to show empirically, the cumulative effect of these 
program components may be due as much to the ability of com- 
munity leaders to organize the planning, packaging, and delivery 
of intervention to the community population as to the effect of 
the program components themselves. 

Is there a single recommended standard, model, or protocol 
for communities to organize for prevention? This is highly doubt- 
ful, for unlike schools, which are equipped for and expect stan- 
dardized teacher training for program delivery, standardized 
program materials, and program delivery schedules, communi- 
ties are more complex, representing diverse interactions of per- 
son, situation, environment, interests, constituents, and needs. 
Some variations in these interactions reflect specific person, situa- 
tion, and environment factors indicative of ethnic /racial popula- 
tions in the United States. 

The purpose of this paper is to consider basic parameters in 
the conduct of community prevention research, with special — 
albeit not limited — application to alcohol and other drug abuse 
prevention research in different ethnic /racial communities. Clas- 
sifying communities according to these parameters suggests an 
initial "blueprint" model for community prevention research, 
with several choice points that enable the mapping of specific 
community needs and characteristics onto the model, including 
the specific needs represented by ethnic/racial communities. 



70 



First, an integrated theoretical perspective is applied to the 
understanding of community prevention research. Second, gen- 
eral factors in community prevention research model building 
are described. Third, specific choice points representing ethnic/ 
racial community considerations in the model are discussed rela- 
tive to four hypothetical case examples. Fourth, an example of 
the model applied to large urban centers that encompass multiple 
communities is briefly described, the Midwestern Prevention 
Project for adolescent alcohol and other drug abuse prevention. 
Finally, gaps in community prevention research are identified 
which represent particularly timely directions for future research 
in the area of alcohol and other drug abuse in the United States. 

An Integrated Theoretical 

Perspective j 

Community organization for prevention, and conceptualization 
of community prevention research, can be expressed as the inter- * j? | 

action of person x situation x environment level factors that are 
bounded by a community (Perry and Jessor, 1985; Pentz, et al., 
1986). Person-level factors are intra-individual variables that pre- 
dict which community leaders will organize and whether they 
will organize effectively; which individuals might be selected 
for prevention program implementation and how well they will 
implement programs; and which consumers are likely to benefit 
most from intervention. In alcohol and other drug abuse preven- 
tion, nonsmoking status and previous civic service involvement 
of community leaders are associated with active participation in 
community organization for drug abuse prevention; younger 
age and acceptance of interactive teaching methods are associ- 
ated with better prevention program implementation among 
teachers; and active participation in program discussion, home- 
work activities, and seeking out parent support for drug abuse 
prevention are associated with greater effects on program-medi- 
ating prevention skills among adolescents (Pentz and Valente, 
1993). 

Situation-level factors involve inter-individual variables. 
Regular communication among leaders of different community 



71 



agencies and centrality of these communications, supportive 
communication between teachers and principals, and positive 
parent-child communication about drug abuse prevention are 
associated with increased community organization and 
decreased drug use for community leaders, program implemen- 
tors, and parents and adolescents respectively (Pentz and 
Valente, 1993). Finally, environment-level factors involve organi- 
zational and system-level variables. Active representation of 
businesses, reallocating existing resources, and concise, well- 
disseminated prevention-oriented policies are associated with 
greater initial and sustained community organization for drug 
abuse prevention, more positive mass media coverage of commu- 
nity organization, and decreased community acceptance and 
social norms for drug use (Pentz and Valente, 1993). 

Two points are central to developing an understanding of 
the complexities involved in applying an integrated person x 
situation x environment perspective to community prevention 
research. The first is identifying what constitutes a ' 'community/' 
Sarason (1974) and others have emphasized that a community 
can be identified on the basis of geographic, social /sociocultural, 
and psychological boundaries; all three boundaries should be 
considered in developing and tailoring of preventive interven- 
tions to the specific needs and resources of the community (Pentz, 
et al., 1986). Second, the integrated person x situation x environ- 
ment theoretical perspective is built on separate theories or mod- 
els that, when used to develop the content, structure, and process 
of preventive interventions, have shown the most promise for 
producing health behavior change in individuals and communi- 
ties. Most prominent among these are the following. 

At the person-level, Bandura's (1977) social learning theory 
represents a major influence on the development of preventive 
interventions that have shown significant changes in reducing 
adolescent health-compromising behaviors, including alcohol 
and other drug use, unprotected sex, and dietary intake (Perry 
and Jessor, 1985). According to this theory, community leaders, 
parents, and student peer leaders in a community must serve 
as credible models of health-promoting behavior. The immediate 
implication of this theory for community organization for alcohol 



72 



and other drug use prevention is that community leaders should 
"practice what they preach/ 7 

At the situation-level, social support theory and theories 
about social normative expectations can be translated to mecha- 
nisms by which community leaders organize themselves, repre- 
sent and support the whole community as a constituency, and 
use the mass media to change perceived and actual social norms 
for alcohol, drug use, and other health-compromising behavior 
(Barrera, 1986; Pentz, et al.). According to social support theory, 
for example, community leaders can develop a community orga- 
nization for prevention and tasks of that organization are struc- 
tured along the lines of physical, fiscal, or emotional needs of a 
community. Achievement of goals and completion of tasks are 
then measured as community resident satisfaction. 

At the environment-level, organization development models 
and social structure theories have contributed to the understand- 
ing of the structure and process of community organization and 
to the patterns of communication between community agencies 
and community leaders (Warren, 1967; White, et al., 1976; Katz 
and Kahn, 1978; Biklen, 1983). For example, Katz and Kahn pos- 



ited that voluntary community organizations operate based on 
four parameters: (1) resources and resource acquisition, (2) a 



defined organizational structure (e.g., top down vs. bottom up, 
lateral vs. hierarchical, on a continuum from participative to 
autocratic leadership), (3) specific production activities and 
assignment of their responsibility to individuals or groups within 
the community organization, and (4) identified outputs or prod- 
ucts, including timeliness for completion (Katz and Kahn, 1978). 
The block model concept and methodology developed in 
sociology is useful in identifying sets of community leaders who 
are most likely to work together effectively, as well as subunits 
or blocks of community residents who are most likely to partici- 
pate in and support local community organization (White, et al., 
1976). Interorganizational field theories add to the block model 
concept by positing that a community organizes for maximizing 
and broadcasting specific values up to a certain threshold (War- 
ren, 1967). Community organization for drug abuse prevention, 
for example, might draw on community leader, community 






73 



agency, and mass media resources to the extent those resources 
for drug abuse treatments are not jeopardized. Also contributing 
to an integrated theoretical perspective at the environment-level 
is diffusion of innovation theory and theories related to chang- 
ing perceived and actual social norms in a community (Pentz, 
et al., 1986; Pentz and Valente, 1993). According to diffusion 
theory, community leaders can strategize about how to promote 
adoption of a preventive intervention between themselves and 
community resident trendsetters; early adoption by these indi- 
viduals up to 10% or 11% of the community population will 
subsequently diffuse throughout the remainder of the commu- 
nity. According to social normative expectation theories, feeding 
back the results of research to a community will correct misper- 
ceptions about the prevalence rates and social norms for health- 
compromising behavior and mediate changes in subsequent 
health behavior in that community. 

A General Model of Community 
Prevention Research 

To be useful to community leaders as well as to researchers, a 
model of community prevention research should specify the 
structure, process, implementation, maintenance, and outcomes 
of community organization. Each can be expressed as a phase 
in community organization; each phase is then expressed as a 
set of constructs with manifest indicators; each construct within 
a phase gains prominence in sequence before the next phase is 
initiated. A simpler version of this model was developed for a 
large multi community trial for adolescent drug abuse preven- 
tion, the Midwestern Prevention Project (see description below 
and model description in Pentz and Valente, 1993). This 10-step 
model to community organization begins with identification of 
the target community and population and ends with a continu- 
ous loop mechanism for maintaining community organization 
and prevention program implementation. Each step is evaluated 
for its completion; the model presupposes that effective commu- 
nity organization cannot occur until all steps are completed. 

The expanded model presented herein allows for more flexi- 
ble choices at each step to accommodate the special needs of 



74 



Dh 



ethnic/racial communities, includes evaluation of initiating 
events as well as long-term community health priorities to pro- 
vide direction respectively to initial community organization and 
maintenance of community organization, and specifies individ- 
ual variables for each construct or step of organization. The 
model is shown in figure 5-1. 

Baseline Community Characteristics 

Baseline community characteristics are entered first in sequence 
in the model. These characteristics are represented by the same 
physical/demographic, social, and psychological constructs 
used to define boundaries of communities, as suggested by Sara- 
son (1974) and Wandersman and Giamartino (1980). Physical 
characteristics include the physical condition of the community, 
size, residential stability, ethnic /racial makeup, income, home/ 
business ownership, urbanicity, and population density, as well 
as the physical resource ' 'plant 7 ' represented by the number of 
financial, informational, and support networks among existing 
organizations within the community (Galaskiewicz, 1979; Per- 
kins, et al., 1990). Social characteristics include the centrality 
of communications among existing organizations; the level of 
support or conflict between organizations, schools, mass media, 
and local government; positive coirimunity acceptance (versus 
passive tolerance) of new and existing ethnic/racial groups; 
acculturation of ethnic /racial groups to the community (versus 
general societal acculturation); and sense of affiliation among 
ethnic /racial groups. Psychological factors include the perceived 
and actual empowerment of the community, existing organiza- 
tions within the community, and individuals to effect health 
behavior change; the perceived and actual readiness of the com- 
munity to participate in such change; and the level of community 
' 'upset' ' or intolerance for existing conditions. 

Initiating Events or Conditions 

The initiating event(s) or conditions that serve as catalysts to 
community organization are entered second in the model. 
Event(s) can represent negative or positive community life events 
to which a community "reacts" by initiating the process of com- 



75 



« 

c 






a 

.0) 




76 



munity organization around the event topic. A negative commu- 
nity life event, such as a tragic drunk-driving death of an adoles- 
cent on the night of graduation, increases community awareness 
of youth alcohol problems and can escalate to the level of a 
perceived community crisis if all population groups in the com- 
munity have directly experienced a similar type of event or have 
been mobilized by the local mass media to empathize with the 
affected group. A positive community life event, for example, a 
civic service award to and broad mass media coverage of a youth 
group that has developed an innovative approach to community 
outreach services, is a much rarer stimulus or catalyst to commu- 
nity organization for prevention. Why? The answer probably 
lies in the complex sets of stimuli in today's high-technology 
society that vie for the attention of individuals within a commu- 
nity on a day-to-day basis. Accumulated on a community level, 
such stimuli or events may come to the prolonged attention of 
community leaders only if they are sufficiently noxious to 
threaten all residents' well-being; otherwise, daily life proceeds 
more or less according to the status quo that even dissatisfied 
residents are sluggish to change (Sarason, 1974) A recent, horrify- 
ing example of a threatening community life event that has 



delayed by sluggishness of the status quo is the recent Los 
Angeles riots and fires in reaction to the Rodney King beating. 
Chronic adverse conditions in a community may also serve 
as a catalyst to community organization. In this case, no particu- 
lar event triggers organization; community residents and leaders 
have already had preliminary discussions about community 
needs; the discussions evolve into community organization. Per- 
kins et al. (1990) have evaluated a model of participation in 
community block associations that showed an association 
between chronically poor physical conditions in a neighborhood 
and subsequent participation among residents who expressed 
an affiliation with the neighborhood. 

Community Leader Identification and 
Preparation 

The third phase in the model is identification of community 
leaders who will organize the community for prevention, and the 



3 * 



spurred community organization for rebuilding but still may be 



77 



process that leaders undergo to prepare for formal community 
organization. Leaders may be leaders of existing formal organiza- 
tions in the community, for example, directors of local health 
agencies, youth agencies, churches, parent groups, schools. If 
the community has had a history of failure with formal organiza- 
tions, however, residents may decide to nominate ' 'grassroots' ' 
leaders from the resident population who are known and 
respected by residents but who have served in no formal leader- 
ship capacity before organization. Several general criteria have 
been used in community studies to identify leaders for commu- 
nity organization. These include positive modeling of the target 
health behavior, prior history of civic service, recognized "gate- 
keeping" function in the community, and commitment to a mini- 
mum two-year term (Vartiaian, et al., 1990; Pentz and Valente, 
1993). In community organization for prevention programs with 
youth, criteria for selection also include whether leaders collec- 
tively cross-cut all or most of community functional sectors, and 
services for youth (Vartiaian, et al., 1990; Pentz and Valente, 
1993). Sectors and services include mass media, education, busi- 
ness, worksite, health /mental health /medical, treatment and 
prevention agencies, youth and social services, youth recre- 
ational services, religious organizations, and relevant ethnic/ 
racial organizations. Virtually no research exists on whether self- 
or other-nomination is more effective in generating a group of 
community leaders who can later collaborate. However, some 
studies have shown that the nomination process is made more 
efficient by a snowball-sampling method of community leader 
identification, By which widely known and respected individuals 
in the community are asked to nominate prospective leader can- 
didates, and those candidates with repeated multiple nomina- 
tions are approached as leaders (Pentz and Valente, 1993). 

Following identification, the proposed model requires that 
leaders prepare for formal organization in three steps: (1) assess- 
ing informally the condition and readiness of the community for 
organization (initial needs /resources assessment), (2) arranging 
and participating in initial training in the etiology, epidemiology, 
prevention, and treatment of the community problem that fos- 
tered the initiating event or condition for organizing, and (3) 



78 



meeting to formally agree to organize. Training in the second 
step may be provided by researchers, clinicians, or other experts 
in the problem area, depending on community leader trust and 
familiarity with a particular area of expertise, and access to 
experts as a resource for organization. Formal agreement to orga- 
nize may expedite the next phase of organization development 
if it is accompanied by coverage of local mass media that are 
sympathetic to the problem and supportive of the identified 
leaders. However, progression to the next phase is likely to be 
impeded if mass media coverage is negative and /or if commu- 
nity leaders do not believe that they are empowered by residents, 
local government, or other existing organizations to address the 
community problem (Florin and Wandersman, 1990). 

In reviewing the results of two studies of neighborhood block 
organizations in racially mixed metropolitan areas, the Neighbor- 
hood Participation Project in Nashville and the Block Booster 3 
Project in New York City, Florin and Wandersman (1990) con- ; J ^J 
eluded that blocks receiving professionally provided training in 
organization development and materials for suggested programs 
were significantly less likely to decline in participation after 10- 
month followup. Pentz and colleagues reported a similar finding 
from Public Broadcasting System stations to organize community 
leaders for drug abuse prevention after the viewing of the Chemi- 
cal People series starting in 1983. Task forces that included a 
professional in drug abuse prevention as a member and trainer 
of other members were significantly more likely to be operating 
after 15-month followup (Pentz and Valente, 1993). 

Community Organization Development 

The fourth phase in the model is development of the community 
organization itself. Katz and Kahn (1978) noted that organizing 
communities effectively to address a particular problem or goal 
requires initial resources, a structure recognized by leaders and 
residents, specific production activities, and outputs or out- 
comes. Prestby and Wandersman (1985) added factors that con- 
tribute to organization maintenance as well as development, 
including the acquisition of other resources, monitoring of imple- 
mentation, and feedback to the community. Figure 5-1 expands 



79 



the model further by including specification of substructures or 
committees to address individual production activities, specific 
training to accomplish these activities, and detailed phases of 
implementation, maintenance, and outcome after initial commu- 
nity organization development. 

Initial community organization will vary as a function of 
individual community differences in baseline characteristics, ini- 
tiating events or conditions, and community leader factors, par- 
ticularly community readiness and community and leader per- 
ceptions of empowerment. Besides these individual differences, 
the particular form of organization will vary systematically 
according to several parameters: resource networks, incentive 
systems, problem acuteness, problem generalization, and prob- 
lem approach. 
jt Resource networks include but are not limited to financial 

support, information /communication, and physical and social 
support and transportation (Galaskiewiz, 1979; Florin and Wan- 
dersman, 1990). Leaders will tend to centralize their communica- 
tions and new organizational efforts around the sources of these 
networks. For example, in a small city dominated by an active 
Chamber of Commerce, any new community organization for 
drug prevention will probably organize its leadership and goals 
around acquisition of financial /business support for prevention 
programs and activities. The structure of organization would 
likely be top-down, following existing business and administra- 
tive structures in the community; since businesses in any commu- 
nity are inextricably linked with local government, local govern- 
ment would be included early in the community organization 
process. 

In contrast, in a disaffected, isolated ethnic /racial community 
with no indigenous business leaders and a distrust of local gov- 
ernment run by Whites, new community organization might 
mobilize around neighbors who represent an active communica- 
tion or transportation network. Organization would be from 
the grassroots level, or bottom-up; local government would be 
excluded or delayed in involvement until the community organi- 
zation as a group felt empowered to demand local policy change 
regarding the community problem. In this latter case, it is con- 



80 



ceivable that the grassroots community organization gains the 
power to mobilize residents' assistance and cooperation in deliv- 
ering programs, goods, and services, but that the local govern- 
ment has the financial resources. In a situation that might other- 
wise produce a stalemate, Florin and Wandersman and others 
suggest a "coproduction" relationship by which the grassroots 
organization and local government assume joint responsibility 
for prevention programs and services: the government for timely 
funding and the organization for quality delivery and dissemina- 
tion (Florin and Wandersman, 1990). 

Incentive systems include material, solidary [sic], and pur- 
posive (Clark and Wilson, 1961). The incentives drive initial and 
maintained interest of community leaders in participating in 
community organization, as well as the general objectives and 
goals of the organization. For example, if community leaders 
and residents perceive correction of a lack of goods, services, 
and facilities as the major means to improve the community and 
eliminate the presenting problem, then the organization will be 
structured to acquire and reinforce participants with materials 
as an initial focus, with tasks and work committees oriented 
toward the acquisition of specific types of materials. Organiza- 
tions will be oriented toward solidary incentive systems if com- 
munity residents and leaders experience a low sense of affiliation 
combined with a need to address the threatening community 
problem collectively and a perception that relationships among 
leaders will enhance their individual prestige. Purposive organi- 
zational development is oriented toward the achievement of 
concrete, visible tasks, for example, a community cleanup cam- 
paign; this type of organization may be short-lived if the task is 
an end in itself. 

Other parameters involve the initiating event or condition. 
If the problem is acute and little is known about its community- 
specific etiology and epidemiology, community leaders may 
decide to organize an initial task force to investigate the prob- 
lem's size and origins before deciding on a course of intervention. 
A task force is usually mobilized quickly, gives rapid feedback 
to community leaders and residents about the scope of the prob- 
lem, and then is disbanded and /or replaced with other, more 



81 



permanent structures to plan, deliver, and monitor interventions 
to address the problem. If the problem is acute and specific, the 
community may organize as a coalition of community leaders 
or as a formal community organization that is independent of 
but includes representatives of other existing organizations. The 
former may have more sanction and support of local government 
at the outset. A coalition is structured to represent a formal 
' 'united front' ' against the presenting community problem that 
includes local government representatives as part of its member- 
ship and has local policy change as an explicit or implicit goal. 

The Center for Substance Abuse Prevention (CSAP) Commu- 
nity Partnership grants require the development of this type of 
community organization to address local problems of drug abuse 
control and prevention. Whether the problem is associated with 
an initiating event or not, if it is chronic and expected to escalate 
and if community leaders determine at the outset that they are 
likely to have adequate resources and commitment to effect long- 
term change, leaders may develop a formal community organiza- 
tion with a structure that is independent of other existing organi- 
zations. For example, as part of the Midwestern Prevention Proj- 
ect (MPP) for adolescent drug abuse prevention, Indianapolis 
community leaders determined in 1987 that they would have 
long-term commitment from school superintendents and long- 
term financial support from the business community (through 
Eli Lilly Endowment, Inc.) to implement and maintain drug 
abuse educational programs and campaigns in the greater India- 
napolis metropolitan area (Pentz and Valente, 1993). Later in 
the same year community leaders founded Project I-STAR and 
registered it with the State of Indiana as a nonprofit community 
organization for drug abuse prevention. 

If the community problem is chronic, pervasive, indicative 
of general adverse conditions in the community, and likely to 
generalize to other problems and events, community leaders 
may opt for general community development rather than devel- 
opment of a specific task force, coalition, or community organiza- 
tion. Florin and Wandersman (1990) define community develop- 
ment as the "voluntary cooperation and self-help /mutual aid 
efforts among residents of a particular locale which aim to 



82 



improve the physical, social, and economic conditions of the 
community" (p. 45). Unfortunately, voluntary efforts of this type 
have tended to suffer rapid decline, with a ' 'mortality rate" of 
50% or more in the first year (Prestby and Wandersman, 1985). 
While little systematic research exists on predictors of commu- 
nity development maintenance, suggested factors include low 
empowerment, sanction, and recognition of the self-help effort by 
local government and agencies; and a lack of access to business, 
health, and research professionals who could manage operations, 
assist in resource acquisition, provide training in prevention or 
other program implementation, and feedback results of develop- 
ment efforts to the community (Prestby and Wandersman, 1985; 
Florin and Wandersman, 1990; Perkins, et al., 1990; Pentz and 
Valente, 1993). 

Finally, the development of an effective community organiza- 
tion effort requires operationalizing goals as a series of tasks 
with definite timeliness for achievement, delegation of tasks to )jj i 

specific individuals or committees that serve as substructures to 

v . - 

the larger community organization, and training or preparing 
individuals or committees in methods to accomplish these tasks. 
The tasks, and thus substructures, vary according to either the 
content of the community problem or the end health behavior 
change target. For example, community heart disease prevention 
programs aimed primarily at adults, such as the Minnesota, 
Pawtucket, and North Karelia Projects, established a formal com- 
munity organization for heart disease prevention as the first 
step of intervention; subcommittees or sub-task forces within 
the community organization were structured according to each 
heart disease risk factor that was expected to serve as the target 
of a program or campaign, e.g., cigarette smoking vs. diet (Lefeb- 
vre, et al., 1987; Bracht, 1988; Puska, et al., 1989). In contrast, a 
community drug abuse prevention program for adolescents, the 
Midwestern Prevention Project, delayed development of a com- 
munity organization for drug abuse prevention until mass media, 
school, and parent program components had already been imple- 
mented and had shown positive results (three years after initial 
intervention in Kansas City; almost two years after initial inter- 
vention in Indianapolis; Pentz, in press). The planned delay in 
MPP community organization was based on previous studies 



83 



A 



which suggested that a primary prevention for youth might have 
to demonstrate initial effects of intervention before a community 
would provide a long-term commitment to drug abuse preven- 
tion (Pentz, in press). Subcommittees were structured according 
to functions or agencies that served youth in general. 

In both the heart studies and the MPP, communities orga- 
nized as part of a research design, with researchers as partners 
sharing the responsibility for the design and community organi- 
zation with community leaders; a formal community organiza- 
tion for prevention was developed with a long-term commitment 
of at least five years; and business, health, government, and 
research professionals were active members of the organization 
from the outset. Because of the research base, training and evalua- 
tion were incorporated throughout each phase of community 
organization, and selection of prevention programs, campaigns, 
and dissemination strategies was based on sound theory and 
research. Because of the types of professionals represented, the 
initial operational structure of community organization was top- 
down, with gradual incorporation of bottom-up support and 
feedback as each community organization was institutionalized 
and ownership shifted entirely to indigenous community lead- 
ers. Also, communications were hierarchical and centralized to 
improve efficiency in decision-making and decrease the probabil- 
ity for misunderstanding or the development of competing inter- 
est groups. Local government involvement helped to ensure that 
long-term tasks and programs would be adopted as a policy 
change by the community. By comparison, communities that 
attempt to organize entirely from the bottom up and /or focus 
too broadly on general community development, with little or 
no input from researchers, health professionals, and business 
leaders, may take longer or fail to identify and achieve specific 
objectives. They may also select interventions based on popular- 
ity or easy availability than probable effectiveness, and eventu- 
ally decline due to a lack of focus or feedback of results (account- 
ability) to the community. 

Implementation 

Actual implementation of the community organization's work, 
or "production input, ,, involves at least five measurable steps: 



84 



(1) outlining specific tasks or programs to be implemented, with 
required resources, delegated personnel, and timeliness, (2) iden- 
tifying and training implementors, whether they are indigenous 
to the community or a combination of indigenous personnel and 
outside experts, (3) implementing tasks or programs according 
to a standardized protocol used for training and agreed upon 
by the community organization, (4) monitoring, evaluation, and 
feedback about the quality of implementation, ideally by individ- 
uals who are independent of training and implementation and 
thus are assumed to be more objective and (5) reinforcing and 
retraining regularly the implementors to maintain their motiva- 
tion to continue implementation and to cope with personnel 
turnover in communities. Consistently, research and program 
evaluation studies have shown that effects of preventive inter- 
ventions on health behavior are highly dependent on the quality 
of implementation as designed (Pentz, in press). Programs with 
no training for implementors and either low levels of implemen- 
tation or extreme deviations from a standardized protocol yield 
results similar to no-intervention control groups (Pentz, in press). 

Maintenance 

While program monitoring during the implementation phase 
involves giving at least periodic feedback to program implemen- 
tors, use of regular feedback of results of community organiza- 
tion and intervention is critical during the maintenance phase. 
If feedback is structured for the public in the form of goals 
attempted and the percentage of each completed, for example, 
the United Way thermometer showing the amount of funds 
raised in a community, community residents can see visible 
progress of community organization on an annual basis. Several 
community heart disease prevention studies and the MPP have 
used annual press conferences for this purpose (Bracht, 1988; 
Pentz and Valente, 1993). Providing a public forum for this feed- 
back prompts mass media representative and community resi- 
dent questions and ideas about the "next step," i.e., selection of 
the long-term focus of community organization. The mass media, 
particularly, can be useful in setting a public agenda to expect 
this next step, and to empower the organization to implement 





I 


. fe N - 








' 




■ 






' 



85 



long-term prevention and health initiatives (Zimmerman and 
Rappaport, 1988; Chavis and Wandersman, 1990). Depending 
on the initiating event and initial focus of organization in the 
community, potential long-term foci include prevention of prob- 
lems that is co-morbid with the initial community problem, for 
example, a long-term AIDS prevention focus that is linked to 
initial alcohol and drug abuse prevention; prevention of chronic 
diseases linked to the initial problem, for example, a long-term 
focus on cancer prevention that is linked to early smoking pre- 
vention; or general health promotion that expands an initial focus 
on nutrition. 

Maintenance will also depend on the acquisition of new phys- 
ical, financial, and social resources to carry out programs that 
represent the long-term focus of the organization (Prestby and 
Wandersman, 1985). Resources should continue to be allocated 
to program monitoring and reinforcement of implementors to 
ensure quality of implementation after the novelty effects of 
community organization have worn off (Sarason, 1974). In addi- 
tion, if dissemination is a long-term focus of community organi- 
zation — more likely if the community organization serves a large 
metropolitan area or contiguous communities — then some 
resources should be allocated to dissemination of training and 
materials. Cost-effective means are the use of a Trainer of Trainer 
(TOT) model, by which previously trained program implemen- 
tors train implementors outside of the community; and the devel- 
opment of a materials clearinghouse, by which one or more 
committees of the community organization periodically collect, 
review, and recommend prevention program materials to other 
communities. Both of these methods are used in the Midwestern 
Prevention Project to disseminate drug prevention program com- 
ponents throughout several states (Pentz and Valente, 1993). 

Outcome 

A detailed discussion of prevention research methods that are 
appropriate to the study of community organization is beyond 
the scope of this paper. However, several previous studies of 
community action and community and school prevention pro- 
grams have yielded recommendations for measurement of com- 



86 



munity organization outcomes. Measurable outcomes of commu- 
nity organization include changes in prevalence rates of the tar- 
get health behavior; generalization of organizational and 
prevention program effects to other related health behaviors; 
changes in community acceptance of the initial problem and 
social norms for the target health behavior; increased centrality 
of community leader and interagency communications and coop- 
eration; increased community leader and resident perceptions 
of empowerment and capacity to empower other leaders and 
agencies for long-term health initiatives through policy change; 
and institutionalization of prevention programs in the commu- 
nity. 

Experimental studies of community organization, with com- 
munity as the unit for randomization, are rare and may be prohib- 
itively expensive. Quasi-experimental studies using communi- . £j 
ties that are demographically matched, convenient, and ready 
for intervention must attempt to control for secular trends and ! jj 
expected confounds that derive from initial differences and 
changes in the physical, social, and psychological characteristics 
of communities (Cook and Campbell, 1979; Van de Ven and 
Ferry, 1980; Airman, 1986; Pentz, et al, 1986; Boruch and Shadish, 
1993). Units of analysis within communities may differ according 
to the target of community organization tasks (Stevenson, et al., 
1992). Changes in community organization networking may best 
be measured and analyzed by block-modeling procedures, net- 
work analyses, and evaluation of mean changes on scales of 
interorganizational relationships (Rogers, 1974; Freeman, 1978; 
Valente and Pentz, 1990). Changes in other variables may be 
assessed with self-report, other-report, and archival measures, 
and analyzed with regression or time-series analyses that model 
or adjust for secular trends. 



Ethnic/Racial Community 
Considerations 



The proposed model for community organization and commu- 
nity prevention research is intended to apply to all communities, 
with individual differences determined by the presence or 



87 



absence or levels of specific variables representing each construct 
in figure 1. However, communities that are populated by one 
dominant ethnic/racial group or mixed ethnic/racial groups, or 
are experiencing a rapid in-migration of one or more ethnic/ 
racial groups, may be subject to several variables that serve as 
"stressors" on the community's capacity to organize effectively 
for prevention compared to other communities. These stressors 
include but are not limited to the following. An Anglo-Saxon 
dominated government and culture in the United States tends 
to attribute ethnic /racial community problems to inferiority, 
genetics, or a failure to socialize; these attributions tend to 
depress community resident feelings of empowerment and cate- 
gorize community leaders and agencies as passive recipients of 
government and social services (Tuchfield and Marcus, 1984). 
The pervasive myth that ethnic /racial communities and popula- 
tions are automatically at high risk for health problems, drug 
abuse, and criminal behaviors has a self-fulfilling prophecy effect 
as well as decreasing perceptions of empowerment (Legge and 
Sherlock, 1990-91). Difficulty of acculturation to a majority — 
usually White — social norm for behavior, and secondary prob- 
lems in acculturation conflict between adults who may prefer 
retention of another culture and youth who prefer rapid accultur- 
ation to majority norms, weaken the capacity of a community 
and its residents to cope with other, daily stressors, such as job 
and school (Caetano and Medina-Mora, 1988). 

Attempting to accommodate to majority norms, ethnic /racial 
communities may show an unusually high tolerance for condi- 
tions that would be considered unacceptable to other communi- 
ties. Thus, by the time a critical incident or initiating event to 
community organization does occur, it may serve as a flash point 
for aggressive or destructive behavior before positive organiza- 
tion can be realized (Oetting and Beauvais, 1991). Finally, access 
to professionals and resources, formalized organizational struc- 
ture, and subsequent longevity of community organizations 
shown in community heart studies and the MPP may be unrealis- 
tic for most ethnic /racial communities, which are isolated from 
these resources. The net result in these communities may be 
a slower, less visible, less powerful community organizational 



88 



process compared to other communities, with a distrust of major- 
ity-dominated government and social services that renders 
achievement of policy change and dissemination outcomes diffi- 
cult. 

Table 5-1 shows four case examples of communities that vary 
in their ethnic /racial makeup, with realistic goals and directions 
for community organization and research. Although the commu- 
nity organizational strategies for each are hypothetical, the com- 
munities themselves are based on real examples encountered in 
prevention studies. The rural, Native American community is 
based on communities participating in the Tri-Ethnic Center at 
Colorado State University (Altman, 1986). The rapid in-migration 
of Vietnamese and other Asian groups along a major interstate 
that crosses a White community is based on a pilot prevention 
project in Tustin, California (Pentz, et al., 1986). The primarily 
Hispanic community within a larger mixed ethnic /racial metro- 
politan area is based on a proposed cervical cancer prevention 
study in East Los Angeles (Pentz et al., in preparation). The 
primarily Black city with community units organized as blocks 
is based on initial efforts by Corporations Against Drug Abuse 
(CAD A) to disseminate portions of the Midwestern Prevention 
Project programs in wards of Washington, D.C. (CAD A, in prog- 
ress). Note that law enforcement cooperation, grassroots organi- 
zation, volunteer resources, minimal demands for professional 
training, and late-stage involvement of researchers predominate 
in these community examples to match organizational strategies 
to existing resources and minimize further stress on day-to-day 
community functioning. 

The Midwestern Prevention Project 

The Midwestern Prevention Project (MPP) is an example of a 
research-based community organization in a large metropolitan 
area. Details of MPP organization are provided elsewhere (Pentz, 
et al., 1986; Alexander, et al, 1988; Pentz, et al., 1990; Pentz and 
Valente, 1993; Pentz, in press; Pentz and Montgomery, under 
review). Briefly, the MPP is a multi-community, multi-compo- 
nent drug abuse prevention program for adolescents being con- 



89 



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ducted in the 26 communities comprising the Kansas City, Kan- 
sas, Kansas City, Missouri, and Indianapolis, Indiana metropoli- 
tan areas. The MPP is conducted as a research trial; as such, the 
design and implementation of all program components are based 
on theory and results of past prevention research. The program 
components are introduced sequentially into schools and com- 
munities to maintain community interest in long-term drug 
abuse prevention intervention. The components, in order, 
include: mass media programming (an average of 31 events and 
programs per year); a school program (11-13 sessions in grade 
6 or 7, followed by a 5-session booster in grade 7 or 8; and a 
multi-component high school environmental change program 
that is currently under development); a parent program that 
includes parent education and organization throughout middle 
school; community organization that includes initial and contin- 
uing training of community leaders in drug abuse etiology, epi- 
demiology, and prevention; a series of short- and long-term pro- 
grams, campaigns, and policy change initiatives that complement 
other program components; and local health policy change at 
the town and city levels, including the promotion of beer taxes 
and smoking ordinances. 

Unlike the community heart studies, community organiza- 
tion in the MPP was delayed until the effects of other program 
components could be fed back to the community as a "success" 
to motivate long-term commitment to organization. The commu- 
nity organization in each site is a formal organization for drug 
abuse prevention that is organized at the city level, with formal 
and informal leaders who represent the interests of each commu- 
nity within the metropolitan area. Eleven committees serve as 
substructures within each organization to implement prevention 
programs, campaigns, and events. The committees are organized 
according to research and community service function-for exam- 
ple, research, medical, and recreational youth committees. 

The predominant ethnic /racial group in both cities is Black 
(approximately 19%), although Hispanic representation has 
grown to over 5% between the 1980 and 1990 U.S. Census. Eth- 
nic/racial interests are given special attention in each community 
organization via a separate committee, the Ethnic /Racial Issues 



96 



Committee, that is structured to conduct additional needs/ 
resources assessments for ethnic /racial groups, adapt program 
content and campaigns to special cultural needs (for example, 
reinterpreting reinforcement of implementors and participants 
in the form of a youth rap contest), and plan effective strategies 
to maximize participation of ethnic /racial groups in programs 
(for example, relocating parent group meetings to churches 
rather than schools). The community organization in Kansas 
City, the Kansas City Drug Abuse Task Force, has been in opera- 
tion since 1987; the organization in Indianapolis, the I-STAR 
Community Council, has been in operation since late 1988. Both 
community organizations have reported positive outcomes in 
adolescent drug use behavior, changes in community social 
norms for drug use, increased inter-leader and interagency com- 
munications and cooperation regarding delivery of drug abuse 
prevention and treatment services, dissemination of the school 
program component throughout their respective states, and ini- 
tiatives that are expected to result in prevention policy changes 
at the school district and city levels. 






Gaps in Community Prevention 
Research: Future Directions 

A recent Office of Technology Assessment (OTA) report (United 
States Congress) and a book published by the Carnegie Corpora- 
tion, "Fateful Choices," (Hechinger, 1992) concluded that adoles- 
cent health is worsening in the United States for the first time. 
The reports represent a call to Congress, State governments, and 
communities to organize for comprehensive health promotion 
at the community level. Community organization would aim 
jointly at community development to get at the root stressors 
that contribute to disease risk, specific community organization 
to prevent disease risk behaviors that are co-morbid for several 
health and social problems, and promotion of healthy alternative 
activities in communities. 

If Congress follows through with these recommendations, 
more research will be needed in multi-focused community orga- 
nization and community organization for health vs. disease pre- 



97 



vention, and community development for primary prevention 
of poverty. Other, more specific directions for research include 
evaluation of how and under what conditions community orga- 
nization at relatively small levels, e.g., street block, can be 
expected to diffuse to much larger levels, e.g., an entire metropol- 
itan area; and the conditions under which a top-down, bottom- 
up, or combined model of community organization may be indi- 
cated in ethnic /racial communities. In addition, before commu- 
nities take on more complex organizational tasks for health, 
systematic evaluation should be conducted on how and how 
effectively communities are using current funds from the Center 
for Substance Abuse Prevention Community Partnership grants 
and other Drug Free Schools and Communities monies. 

Final Caveats: Contraindications 
to a General Model 

This paper focuses on adaptations of a general model of commu- 
nity prevention research to ethnically and culturally diverse com- 
munities, based on theory and previous research findings. How- 
ever, reflecting the predilections of researchers and academicians 
who developed these theories and research findings, it could be 
argued that the general model described here is a rational deci- 
sion-making model built on Western (primarily Anglo-Saxon) 
principles of leadership and community organization; culture- 
free concepts of behavior change, most notably, behavior modi- 
fication concepts from social learning theory; and initial preven- 
tion education strategies that rely on person-level predictors of 
and solutions to drug abuse. Evidence is growing to support 
adaptations of this type of general model to diverse populations. 
The most recent example may be the current organizational 
efforts of communities participating in Robert Wood Johnson's 
Fighting Back program. Two years after planning community 
wide drug abuse prevention, culturally and ethnically diverse 
communities that initially attempted to organize from the per- 
spective of community vs. expert-driven initiatives have evolved 
through organizational, process, and structural models very sim- 
ilar to those presented here (Pentz, 1993). Nevertheless, at least 



98 



three exceptions should be noted for which any adaptation of 
a general model may be contraindicated. Since none of these 
exceptions have been thus far evaluated or validated as contrain- 
dications, they are presented as hypothetical constraints to adapt- 
ing the type of general community model of prevention research 
described in this paper. 

The first contraindication is a community with a negative 
history, if not outright failure, of previous researcher involve- 
ment in community organization for prevention. This contraindi- 
cation pertains to any community, regardless of ethnic /cultural 
representation. The negative history would go far beyond simple 
distrust of government services or professional involvement as 
discussed earlier, to outright refusal of the community to adopt 
or follow any protocol that is specified a priori. In this case, 
the community should anticipate a development period that is 
characterized by multiple regular challenges from competing 
interest groups as they vie for attention and support. Formalized 
data collection may be antithetical to the interests of all groups. 
However, informal accounts of community process can be col- 
lected to document the community's "story" for future self- 
accountability and for re-creations of the story in other communi- 
ties interested in replicating the process. 

The second contraindication is a community with such 
diverse interest groups that consensual, organized leadership 
for prevention is not possible. Like the previous example, this 
contraindication pertains to any community, regardless of eth- 
nic/cultural representation. In this case, it is conceivable that 
diverse groups develop their own separate agendas for preven- 
tion within the community, and meet only temporarily for agree- 
ing to principles of least harm or infringement to each other and 
to the community. For example, after the civil unrest in Los 
Angeles riots, gang leaders met and formed a temporary truce for 
peace, without relinquishing their own operations or developing 
concrete plans to positively restructure their communities. Faced 
with this type of contraindication to a general model, a commu- 
nity may be expected to progress through several slow stages 
before organization for prevention can be attempted, from a 
temporary alliance for least harm, to some community healing 



99 



ti 



after harm has been reduced, to tentative consideration of pro- 
posals that promote growth of separate interest groups while 
maintaining least harm to others. 

The third contraindication is a community with perceptions 
about drug abuse, prevention, and treatment that are radically 
different from rational, intrapersonal, time-limited, and expert- 
dependent theories and research of Western, White culture. This 
contraindication is specific to communities that are predomi- 
nantly ethnic /racial, either in terms of representation by a single 
ethnic or cultural group or by diverse groups. For example, a 
recent review of anthropological, sociological, and psychological 
research on health attributions indicated that ethnic /cultural 
minorities construe illnesses such as drug abuse as a long-term 
process caused by natural, interpersonal and environmental, and 
supernatural (including mystical retribution, hot-cold attribu- 
tions, and bad blood) factors (Landrine and Klonoff, 1992). Fur- 
thermore, prevention and treatment are perceived as an ongoing, 
evolutionary community and family healing process rather than 
as a time-limited strategy developed by health experts. Research- 
ers attempting to work in such communities are advised to con- 
duct a thorough formative evaluation before determining 
whether any rational, deterministic model can be applied to 
prevention. Rather than a prevention needs and resources' 
assessment based on available services, a formative evaluation 
would first consist of evaluating how the population identifies 
or labels drug abuse and its symptoms, attributes causality, antic- 
ipates consequences, and expects a course and duration of 
"cure." If the formative evaluation yields findings that do not 
fit current theoretical and research schemas of drug abuse pre- 
vention, the researcher's subsequent role may be observer and 
documenter of a community process that may or may not develop 
into an organizational model, and may or may not be generaliz- 
able to other ethnic /racial communities. 

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104 



6 

Ethnic Communities and 

Research: Building a 

New Alliance 



Fred Beauvais 



Introduction 

The original version of this article was much different from what 
follows. During the first writing I had in mind the notion that 
those who did social research were somehow inherently at odds 
with those who were the subject of their inquiry. I was following 
the supposition that researchers had a world view that differed 
significantly from non-researchers, and in particular differed 
from ethnic minorities, and that these differences set the stage 
for a series of conflicts that had to be overcome if social research 
was to achieve its goals. This belief in opposition, conflict resolu- 
tion and compromise is rooted in the theories that commonly 
drive cross-cultural research. Cultures, including research as a 
culture, have been viewed as competitive; and, to achieve accom- 
modation, one side or the other must give ground. I pursued 



The preparation of this paper was supported in part by grants from the National 
Institute on Alcohol Abuse and Alcoholism (AA08302) and the National Institute 
on Drug Abuse (DA03371). 



as 



105 



this line of thinking in the original writing; but, I was disturbed 
by the feeling that something did not ring true. 

When I was doing the final revisions of this paper it occurred 
to me that what I was writing was not congruent with the most 
recent research of our laboratory, and that realization accounted 
for my unease. We have recently theorized, and have partially 
substantiated, that the coming together of two cultures need not 
be marked by conflict and that cross-cultural encounters can 
be mutually enriching with no necessary loss to either culture 
(Oetting and Beauvais, 1990). Is it not possible to see the coming 
together of scientific and ethnic communities in the same non- 
competitive light? Armed with this insight, I went on to revise 
the paper and with much less anxiety. This change in focus is 
reflected in the change in titles: the original article was titled 
"Reconciling the Requirements of Science and Community in 
Cross-Cultural Research," which clearly connotes a different 
view from "Building a New Alliance." 

The Culture of Science 

Using the term culture in its broadest sense, scientific research 
forms a culture by itself. There are specific beliefs, values, and 
behaviors that accompany the scientific quest for knowledge. 
The presence of rituals is even an essential element of science, 
as evidenced by dissertation defenses, group behavior at confer- 
ences, study sections, the requirements of professional publica- 
tion and the like. In the course of its business, the culture of 
science routinely comes into contact with other cultural groups, 
often resulting in awkwardness, if not outright discord. The most 
common encounters are with non-scientists, and, while these are 
often marked by some uneasiness, there is often a larger, shared 
cultural background that allows for a modicum of communica- 
tion and understanding. Physicians, for instance, are usually able 
to call upon shared language and metaphors to help their patients 
understand their illnesses and treatment. 

When science has to transcend not only its unique culture 
but also to cross boundaries presented by ethnic and nationality 
differences, the potential for tension increases. This is a common 



106 



circumstance when social scientists are involved in the investiga- 
tion of problems in a culture other than their own. In these 
instances there are layers of differing expectations, world views, 
and perhaps language that must be adapted to if the work of 
science is to be successfully completed. It is too often the case 
that the scientist and the community are operating in different 
spheres and toward different ends. The net result is mutual 
disappointment with the research process and perhaps even lin- 
gering distrust. 

The origin of much of the tension that occurs when different 
cultures come in contact is the belief that the cultures are in 
competition and that if the values of one culture are embraced, 
then the other culture is diminished. The bulk of the literature 
on acculturation is based on this premise whereby cultures are 
placed at polar opposites on a single, linear dimension (Oetting 
and Beauvais, 1990). Movement along this dimension in a partic- 
ular direction implies that if a person is gaining identification 
in one culture, that person is losing in the other. These linear 
models assume, for example, that if someone from Puerto Rico 
wants to become a successful college professor in Seattle, he 
must leave behind many rich cultural elements he has been 
imbued with in his native upbringing. Another tenet frequently 
encountered in these models is that if a person takes on identifi- 
cation with another culture there is an inherent transition period 
that is marked by stress and conflict. This is only resolved when 
identification is achieved with the new culture and the old values, 
behaviors, and customs are left behind. 

The linear model of acculturation, emphasizing cultural con- 
flict, has not been particularly helpful in explaining the process 
of changing cultural identification. An alternative model has 
been proposed that does not involve the notion of inherent con- 
flict when cultures come in contact (Oetting and Beauvais, 1990). 
Applying this model to the encounters between scientists and 
non-scientists, particularly in cross-cultural settings, reduces the 
focus on conflict between cultures and enhances the possibility 
that a more effective, workable alliance can be built. 

This alternative model of cultural identification is presented 
in figure 6-1. Each line represents a different culture: one repre- 



107 






sents Hispanic culture, for instance, and the other Anglo, or 
White American, culture. The base point, or origin where the 
lines meet, marks no identification with either culture. A person 
who is highly identified with Hispanic culture could be said to 
exist at some distance from the base point (the farther along on 
the line, the greater the strength of identification with Hispanic 
culture). At some point, however, the Hispanic person, by choice 
or circumstance, may meet Anglo culture and begin to assimilate 
some characteristics of that culture. This person's identification 
can now be visualized as moving out at right angles to the 
Hispanic dimension in the direction of Anglo identification. The 
important point is that by moving in the direction of increasing 
Anglo identification, it is not essential to lose one's "Hispanic- 
ness"; that is, there is no necessary movement toward the base 
point. The person can retain as much of the original heritage as 
desired, while adopting any level of identification with another. 
The culmination of this process might involve complete identifi- 
cation with both cultures (in other terminology, "biculturalism"); 
when this occurs the person can be visualized as being in the 
upper righthand corner of the space defined by the two axes. 

If, in the model, we replace one culture with // science ,/ and 
the other with an ethnic culture, we have a model with strong 
implications for cross-cultural research. In the present paper, 
those from an ethnic culture can become conversant with the 
goings-on of science and the culture in which it exists without 
necessarily detracting from their native cultural beliefs, values, 
and behaviors (See figure 6-2). In the same manner, members of 
the culture of scientific research can come to understand and 
appreciate the values, beliefs, and traditions of ethnic groups 
with whom they may be working, and in doing so they do not 
have to "compromise" or leave behind their scientific values. 

It is important to note that there are varying levels at which 
identification with another culture can take place. The researcher 
may never become completely identified with another culture, 
but there must be substantial movement in that direction if there 
is to be a productive alliance. A researcher, for instance, can gain 
knowledge about the traditions of an ethnic culture but not 
consider these traditions to have any legitimate value in the 



108 



A 




o 












3 






*^ 






3 






o 






o 






c 






(0 






Q. 






0) 






X 




• 






P 




Anglo Culture 


F/gure 6-7. 


77ie Relationship Between Hispanic and Anglo 


Cultures 





v. 




study of social problems. For instance, a particular tribal group 
may follow certain behaviors surrounding taboo topics or events; 
and, while the researcher probably could describe these behav- 
iors, little or no identification is achieved and the researcher may 
dismiss these behaviors as "superstitions" that have no place in 
"correct behavior/' This scientist is not moving out into the 
bicultural space and is sticking to the ' 'scientific' ' culture and 
only observing at a distance. Science and the native culture at 
that point may be in conflict. When the scientist later describes 
the behaviors in unsympathetic terms, the native people may 
resist further involvement with the scientific process. While it 



109 




Indian Culture 



Figure 6-2. The Relationship Between the Research Culture 
and Indian Culture 



may not be necessary for researchers to incorporate those taboos 
into their own value system, they must at least "suspend disbe- 
lief" and acknowledge that taboo behavior is a valid part of the 
tribal world view and something to be seriously reckoned with in 
conducting research. In essence, the researcher need not become 
totally accepting of the world view of another culture to guide 
his or her own behavior. However, there is a need to become 
identified with that culture to the extent that its world view is 
seen as valid and to expand research strategies to accommodate 
the assumptions of that world view. More will be said on this 
point later. 



no 






Conflict can arise, and it does so primarily because of the 
failure to appreciate and to identify, with the needs that are 
inherent in the culture of another, thus not taking these needs 
into account when trying to negotiate a cross-cultural inter- 
change. The theme of this paper, then, is to identify the possible 
needs of the culture of science and the cultural needs of ethnic 
communities, to show how increasing identification with both 
cultures can reduce conflict and help build working alliances. 

Community Needs and the 
Purpose of Scientific Research 

In its purest form, the intent of science is to accumulate knowl- 
edge and understanding of natural phenomena with no particu- 
lar requirement that the findings will be useful in the sense of 
creating change in the world. This is in sharp contrast to the needs 
of the community that may be experiencing social problems, in 
ethnic communities all too often accompanied by high levels of 
human misery. Unfortunately, and for a host of historical reasons, 
ethnic communities are often in the greatest need of immediate 
action to remedy social problems. When these communities are 
approached by the scientist interested in study of problems, there 
can clearly be a mismatch in expectations: the scientist is looking 
to further knowledge while the community needs a resolution 
to a problem. The mismatch, however, need not be overdrawn, 
since there does not have to be anything contradictory between 
rigorous science and social action; the resolution lies in the need 
for the researcher to understand the need for action and to design 
research that addresses problems in a way that leads to short- 
term solutions, while adding to basic knowledge in a scientific 
field. An example may be useful. 

A social scientist may have an interest in the social and 
psychological conditions leading to patterns of suicide among 
adolescents and may want to test out some cross-cultural hypoth- 
eses by doing research in ethnic communities. Pursuing this 
interest would require a great deal of data collection, statistical 
comparison, perhaps some complex model building, and ulti- 
mately the publication of research results. To this point the 



111 



requirements of science are met, but it is entirely possible that 
these results may have little practical application in the commu- 
nity. It is quite often the case that this type of research is con- 
ducted in communities where the problem is particularly severe 
and thus the need for solutions is urgent. When the scientist 
gains prestige and publication and the community gains nothing, 
it can be viewed as exploitation. With forethought and planning, 
however, it is possible to attend to both the research goals and 
the needs of the community. 

The key to meeting both sets of goals is collaboration in 
setting the research agenda. Community people need to be 
involved so that they can state their needs in terms of the types 
of answers that would help them address the problem. This 
process need not be disruptive to the scientific process but can 
be seen as an extension of that work to the practical level. Early 
dialogue has the advantage of aiding the research effort by mak- 
ing certain that the issues addressed are framed accurately, thus 
leading to more accurate research outcomes. Knowledge of the 
local context may modify the research questions and ensure 
that the right questions, and thus the most useful answers, are 
ultimately arrived at. 

It must be recognized that sometimes science can have 
abstract goals that do not easily lend themselves to practical 
application. In these instances it is appropriate to develop an 
additional set of research goals that address the immediate needs 
of the community but are still congruent with the thrust of the 
research efforts. For example, a research project may be address- 
ing the theoretical links between psychosocial factors and sub- 
stance abuse among adolescents, but at the same time efforts 
could be designed to incorporate these findings into a drug 
prevention curriculum for use in community schools. 

For its part, the community must develop an appreciation 
for the time demands of research and understand that immediate 
recommendations for problem resolution are not always possi- 
ble. One common type of cross-cultural research, for instance, 
is the replication of findings from the majority population to an 
ethnic group. For example, suppose it has been found that a 
particular intervention has been shown in the general population 



112 



k. 



to be effective in reducing drinking among pregnant women and 
thus a reduction in the rates of fetal alcohol syndrome. In an 
ethnic community experiencing high levels of fetal alcohol syn- 
drome, there may be a serious and immediate need to adopt 
this type of program. The researcher, however, may see a need 
to test the efficacy of the intervention within the ethnic popula- 
tion. It is possible that within a different cultural context the 
program that proved effective elsewhere may not work, or may 
potentially have a harmful effect. Through collaboration with 
the researcher, community people can come to realize that this 
cross-validation effort is often necessary (i.e., a requirement of 
the culture of science) to see if the original results generalize to 
their community. 

Evaluative research is another area where the lack of a bicul- 
tural orientation can create a mismatch of expectations. Programs 
to address social problems are usually implemented because 
there is a serious and immediate problem that needs to be 
addressed. The researcher's interest is in questions regarding 
the efficacy of the program in meeting predetermined goals. 
Routinely, these goals are specified and measurements are used 
to assess their attainment and to determine which aspects of the 
program are effective and, if possible, why. The ultimate objec- 
tive of this type of inquiry, from a scientific perspective, is to 
see if the program has a coherent enough theoretical base to be 
transportable to other contexts. 

In some ethnic communities, however, the objective may be 
much more pragmatic and may involve many questions that 
cannot be answered through the usual empirical approaches. 
Quite often these questions are rooted in social and cultural 
issues and may include: Is this program congruent with our 
cultural values and traditions? Do the community elders value 
this program? How does this program fit in with already existing 
human service programs? Is the program displacing existing 
programs? Will the program add new employment to the com- 
munity? Once again, it is not necessary to see the goals expressed 
by the researcher and those of the community as being in opposi- 
tion to one another. The researcher needs to be aware of these 
other domains of inquiry and make certain that the evaluation 



113 



plan incorporates answers to the questions that are deemed 
important by the community. The reasons for this are both ethical 
and pragmatic. The researcher cannot assume that his or her 
way of framing research questions is the only valid one; to do 
so perpetuates the same colonial attitudes that have plagued the 
relationship between research and ethnic communities in the 
past. Pragmatically, if the community does not receive the 
answers it deems necessary from a piece of research, the opportu- 
nities for future collaboration will be greatly diminished through 
restriction of research by ethnic communities. 



Ways of Knowing 



The problem of misunderstanding between researchers and eth- 
nic community people may go even deeper than differences in 
expectations regarding the purpose of research. There may be 
fundamental differences in world view and ways of structuring 
knowledge that must be considered. 

Western scientific thinking follows a fairly consistent and 
accepted (at least by researchers within that specific culture) set 
of rules for the accumulation of knowledge. These rules are 
largely quantitative and rely heavily on statistical inference. The 
success of science in solving certain problems has led many 
researchers to become culture bound and to lose sight of the fact 
that knowledge can be accumulated in a number of alternative 
ways (See Berry, 1980, and Goodenough, 1990, for an extended 
discussion). Many cultures, for instance, often rely on more quali- 
tative processes to derive meaning from their observations and 
to transmit this meaning to others. In some cultures there are 
strong oral traditions where information is conveyed through 
stories or legends passed to younger generations by elders. Fur- 
thermore, truth or knowledge rarely hinges on linear logic with 
successively linked pieces of evidence leading to a conclusion. 
Rather, for some cultures, knowledge comes from an accumula- 
tion of information and sometimes from seemingly disparate 
sources. Pieces of knowledge are woven together, often in alle- 
gorical fashion, and conclusions may not be evident to someone 
not familiar with the cultural themes. The point is that the usual 



114 



quantitative research strategies may lack face validity in many 
ethnic communities. The collection of numerical data does not 
appear relevant, and there may be resistance to data collection. 
This seeming disparity between cognitive approaches need 
not become a barrier, however, since multiple methods of 
research can be used, with each source of information enriching 
the other. Fortunately, there is an increasing appreciation within 
the research community for ethnographic approaches that can 
be used to capture meaning within cultures with strong oral 
traditions or more metaphorical cognitive styles (Gilbert, 1990: 
Goodenough, 1990; Ramirez, 1983). These approaches are more 
likely to be accepted within ethnic communities and can be used 
with the quantitative methods usually associated with Western 
science. Again we have the opportunity for different cultural 
traditions to be blended and used simultaneously, rather than 
to be seen as in opposition. 



Access 






i 



Research has developed a checkered reputation in ethnic commu- 
nities over the past few years (see, for example, Manson, 1989). 
The reasons for this are varied but typically are due to the oft- 
repeated failure to perceive the multiple cultural needs of both 
the researcher and the community. Regardless of the origins of 
the adversarial stance often found between ethnic communities 
and researchers, the researcher must be aware of these feelings 
before a community is approached and must recognize their 
legitimacy. Without this sensitivity to history, the researcher 
will likely misread the mood of the community and encounter 
roadblocks in gaining access. 

Access to a research population is contingent on both the 
needs of the researcher and the needs of the community. Ideally, 
the balance of needs is equal, but it has quite often been the case 
that ethnic communities have been perceived as field laboratories 
to be used for the convenience of the researcher. This can lead 
to a sense of exploitation within the community and an unwill- 
ingness to participate in future research efforts. It is unfortunate 
that many communities feel that they have been sufficiently 



115 



"burned" in the past that they have put stringent regulations 
on further research. Sometimes the problem has become severe 
enough that the community has imposed a total ban on research 
(Trimble, 1977; 1988). While there may be legitimacy to this type 
of feeling, the community must also realize that research can, 
under the right conditions, lead to problem resolution and that 
banning of research can be self-defeating. There are many anti- 
dotes to this type of community resistance, most of which stem 
from an attitude of persistence and respect and a willingness to 
learn on the part of the researcher. 

A major error in many failed research projects is the lack of 
sufficient lead time in which the groundwork for the project 
can be established. Sufficient time must be allotted in which 
researchers can meet with community people to discuss the 
planned research and to give the community an opportunity to 
help shape not only the goals of the research but also the proce- 
dures that will be used. The importance of this planning stage 
cannot be overstressed, and it is important to allow enough time 
for this process to take place. This is the time in which differences 
in world view often emerge and the process of cross-identifica- 
tion between cultures starts to take place; community people 
can be educated regarding the needs of research and researchers 
can gain deeper insights into the cultural milieu in which they 
will be working. 

A major issue to be addressed early in the research process, 
and indeed one that needs to be revisited throughout, is who is 
responsible for change that might result from the findings of the 
research; this is important when the issues under study are of 
a social nature. The history of ethnic group social change in the 
United States is one where outside groups have attempted to 
impose solutions to social problems; for the most part this has 
not been successful. For instance, for over 200 years federal gov- 
ernment policy held that American Indian communities would 
be better off if their children were educated in boarding schools 
run and staffed by non-Indian teachers. This has led to poor 
educational achievement for many Indian youth and further 
has disrupted family functioning, since children were essentially 
raised in a non-family environment. Today there is a strong trend 



116 



toward educating Indian youth in their home communities and 
to a growing extent by members of their own tribe. 

It is well accepted in the field of community development 
that the deepest and most lasting changes in community life are 
generated from within the community and not by outsiders who 
have no lasting investment in the welfare of the community. It 
is reasonable, therefore, that the impetus for change come from 
community members themselves. Research results can be useful 
by providing data regarding the need for change, the direction 
of change, and the extent of change, but the researcher is not 
the best change agent. As indicated, these expectations must be 
made clear from the beginning. Because it has happened so often 
in their history, it is not unusual for an ethnic community to 
assume that the outside research team will take the lead in imple- 
menting change once research results are available. If the 
researcher is not expecting to take on this role, and the commu- 
nity is expecting it, there will be a sense that an implied contract 
has not been fulfilled and resentment may follow. 

While the above cautions are especially pertinent in research 
projects involved with social research, they are also relevant to all 
types of investigations, including medical research. A physician 
may, for instance, be able to pinpoint the underlying causes of 
an outbreak of infectious disease in a community and devise a 
plan for its treatment. Although this may involve straightforward 
medical and public health procedures, compliance with those 
procedures may well be contingent on local social and cultural 
factors. The people in the community must be educated as to 
the necessity for compliance, cultural barriers to the treatment 
must be addressed, and the indigenous health care workers must 
be enlisted in the effort. Lack of attention to any of these links 
to compliance could well lead to poor adherence to the treat- 
ment regimen. 

Apart from recognizing and acknowledging whatever feel- 
ings there are in a community about research, access for the 
researcher is also contingent upon knowing and using the proper 
channels for approval. Ethnic communities, trying to retain a 
sense of ethnic identity, have often developed a certain level 
of autonomy that is maintained by both formal and informal 



117 









regulatory structures not found in mainstream communities. 
American Indian communities present the clearest example, 
since they see themselves as independent nations with a direct 
formal relationship with the United States government. The fact 
that a research project may be federally funded, however, does 
not automatically imply access to Indian communities. There are 
many local government structures that must be consulted and 
that must provide approval before research can be sanctioned. 

In other ethnic communities the controls are less formal, yet 
there may be important gatekeepers who must be apprised of 
proposed research and must give approval. Besides approval 
by gatekeepers, researchers must be sensitive to the prevailing 
attitudes in the community with respect to specific research con- 
tent. In many Indian communities, for instance, there are topics 
that are either taboo or are considered inappropriate to be dis- 
cussed publicly. In other communities a particular line of 
research may be perceived as changing the power relations in 
a community and thus be seen as threatening to certain factions. 
Proposed research that is not in tune with the local values and 
beliefs and political dynamics will have little chance of being 
approved by the community. Once again, these cautions apply to 
all types of research, not just that which involves social problems. 
Agriculture, for instance, is strongly rooted in the cultural beliefs 
and value systems of many ethnic communities. While it may 
seem reasonable to study ways of increasing crop or animal 
production through scientific research, such a project may not 
be tolerated if it is viewed as infringing upon strongly held 
beliefs regarding fertility and the spiritual relationships with the 
natural world. 

On the community's part, to the extent possible, the channels 
of approval for a particular piece of research must be made clear 
to the researcher. An investigator may believe that the proper 
sanctions have been obtained only to find out midway through 
the project that there are major objections to this work by seg- 
ments of the community who are in a position to block its comple- 
tion. The informal nature of many control structures in ethnic 
communities often makes it difficult to discern where approval 
should be sought, and it is often necessary to rely on local collabo- 



118 



rators to obtain this information. Even when formal approval 
has been obtained, however, the researcher must maintain an 
ongoing awareness of attitudes in the community. It is a common 
occurrence for individual community members to voice objec- 
tions to a particular piece of research and to threaten the project 
with termination. Without knowing the prevailing or dominant 
attitudes of the community, it would be easy to misread isolated 
complaints which might interfere with the research. 

While it is important that the concerns of individual commu- 
nity members be heard and given a considered response, it is 
incumbent upon those in the community who provided the origi- 
nal approval to protect the integrity of the research and to make 
certain that vocal individuals not override what in general has 
been deemed valuable research. 



Research Design 

Whenever research is taken from the laboratory to the field, a 



great number of complications can arise, since rigorous designs 
are difficult to construct and maintain. If the proposed research 
is to have any value from a scientific perspective, or in terms of 
resolving community problems, it must be conducted as rigor- 
ously as possible. It is occasionally possible to set up a true 
experimental design in the field, but the complexities of the real 
world most often dictate that quasi-experimental designs are the 
most feasible. Even these designs, however, carry with them the 
need to structure the research in systematic ways that often 
conflict with the needs and capabilities of the community, or 
that are misunderstood by the community. Random selection of 
research participants and the need for control groups are two 
of the most common issues that create problems for field research. 
The scientist needs to be certain of the validity of any piece 
of research, but the community may see these as unnecessary 
trappings that only delay the implementation of sorely needed 
interventions. A community that is facing a rapid increase in 
cases of HIV infection, for instance, will understandably be impa- 
tient with the need for scientific rigor. It must be recognized that 
local service providers are often subjected to strong expectations 






i 






119 



from the community to provide the best service to the most 
people. Parents, for example, may express dismay that their 
children are not receiving the benefits of an experimental AIDS 
prevention program because they are in a control group. 

Compromises are certainly possible when research designs 
are developed, but the community must be aware that there is 
a level of compromise that will destroy the quality of the research. 
When this happens, the value of an experimental intervention 
may be unknown. The study will not provide knowledge that 
is credible or that can be generalized to other communities. For 
example, to obtain the maximum amount of scientific rigor, a 
no-treatment control group may be incorporated as part of the 
design. However, it might be appropriate to guarantee that those 
in the control group will receive treatment in later stages of the 
project. From a scientific viewpoint this may not be necessary, 
and may greatly increase the cost of the project, but from an 
ethical and collaborative point of view it may be essential. 

Not only must the needs of good science be protected, but 
also there is the need for researchers to be responsive to funding 
agencies and their peer review committees. Research funds are 
limited, and any community-based project must compete with 
other projects, many of which can incorporate very sophisticated 
designs. Research designs that are seriously weakened by prag- 
matic needs of the community will not be funded. The commu- 
nity needs to increase its sophistication about the scientific cul- 
ture to improve chances that it will be involved — that at least 
some of its members may receive treatment or that lessons will 
be learned that will eventually improve the well-being of its 
members. 

One of the most straightforward, but often overlooked, reme- 
dies to this situation is the sharing of information with commu- 
nity members about the needs of good science — that is, striving 
for an increase in community identification with the culture of 
science. Researchers often assume that ethnic community mem- 
bers cannot understand the work of science and thus pass up a 
good opportunity for education and acculturation to the ways 
of science. Much of this can be accomplished through the use 
of local people who can ' 'translate" the scientific concepts into 



120 



a language that is meaningful to the local population. This pro- 
cess is also valuable when it operates in the other direction; 
knowledgeable, local contacts can be used to help the researcher 
in the understanding of local cultural values. The major theme 
throughout this paper has been that there is nothing that prevents 
individuals from embracing elements of more than one culture 
and that knowledge of other ways of doing things is an enriching 
process, not one that implies conflict or contradiction. 

Data Collection 

Research often carries with it the need for extensive data collec- 
tion. Most field research is complex, involving the interplay of 
multiple, interacting factors, a great many of which may need 
to be assessed in a particular piece of research. Quite often this 
measurement load places a great burden on community 
resources and personnel. This burden is especially heavy in many 






ethnic communities where resources are scarce and the service 






6 






systems are already stretched. School systems, for example, are 
a convenient source of data on children, yet the demands on the 
time of schools have recently become enormous. School systems, 
on Indian reservations, for example, are often underfunded and 
understaffed, so it is unreasonable to expect that teachers can 
take hours out of their schedules for data collection. Health 
systems are also frequently only barely able to provide for the 
basic health care of their patients and cannot spare the effort 
needed to do further assessments that might be required for a 
research protocol. 

Once again, the tolerance of the community must be called 
upon, and it must recognize the need for adequate data collection. 
If sufficient information is not collected there will only be simplis- 
tic answers to complex questions. Researchers, however, must 
also recognize the demands they are placing and must be willing 
to negotiate the level of data collection that is absolutely neces- 
sary. Researchers are curious by nature and find it difficult to 
pass up the opportunity to examine a problem from all directions. 
It is often possible to critically examine the research questions 
being asked and to pare the data collection to those questions 



121 



that are central to the important research hypotheses, thus reduc- 
ing both stress and resistance among community members. 

Publication of Research Results 
and Community Reputation 

Publication of research findings for scrutiny by peers is a hall- 
mark of science. This self-correcting process assures the accuracy 
of research findings and places them in a forum where knowl- 
edge can accumulate within a discipline. Researchers addressing 
social problems, however, often face a dilemma when it comes to 
publication. By their very nature, social problems entail sensitive 
information that may reflect negatively on the communities and 
the people with whom the research is conducted. A community 
that is beset by numerous problems may be reluctant to have 
yet one more piece of information appear publicly that would 
cast them in a negative light. 

Although publication is a necessary part of research, a great 
deal of sensitivity needs to be used in the way reports are written. 
It should be obvious that individual anonymity be protected; 
however, there have been instances where individuals or families 
were identified in research publications or their identities were 
so thinly veiled that identification was possible by other people 
in the community. 

Usually it is not necessary to use specific location names 
in reporting research results. This is especially important with 
smaller communities where there may be a tendency to attribute 
identified problems to all of the individuals who live there. 

One procedure that has proven helpful in avoiding problems 
with publication is to have people from the community review 
articles before they are published. There should be agreement 
that this review is for protecting the reputation of the community 
and not to change any of the data or to alter conclusions that have 
been drawn from the data. The scientific integrity of publications 
needs to be protected as well as the privacy of the community. 
This type of review has the added advantage in that local people 
can often provide cultural insight that helps expand and enrich 
the interpretation of the research findings. 



122 



An often overlooked aspect of the dissemination of research 
information is the community's need for feedback and under- 
standing of the research results. One reason for participation may 
be that they have seen the possibility of resolving a particular 
problem, and they have the right to information in a form that is 
clear and understandable. Special reports of the research findings 
and open community meetings are common avenues for this 
type of communication. In many ethnic communities it is often 
appropriate for someone from the community to become conver- 
sant with the research findings so that he can convey the informa- 
tion in a way that is understandable and is culturally appropriate. 

Research Consistency and 
Community Dynamics 



Typically it is difficult to change a research design once it has 









been established. The integrity of the outcomes can be jeopard- 
ized if the control conditions are altered, if the data collection 
procedures are changed, or if access to participants is halted. 
Periodic changes in the community structure or political reality, 
however, may seriously interact with the conduct of an ongoing 
research project. This is more often a problem in highly polarized 
communities where factions may have taken a position with 
regard to the value of the research. 

The researcher must take an extremely cautious position 
when there are strong divisions in a community and when the 
research project has become a point of contention. It is often 
necessary to alter the goals of the research and work toward 
compromises that do not interfere with the dynamics of the 
community. Despite a strong desire to maintain the integrity 
of the research project, it is usually counterproductive, if not 
presumptuous, for the researcher to attempt to alter the political 
conditions in a community. If the work of the research project 
could benefit from some type of community intervention, this 
should be done by a community member who is familiar with 
the research and has legitimate influence in the community. Such 
liaisons should be built in from the beginning of a project, and 



123 



those local community members should take the lead in preserv- 
ing the conditions necessary for completion of the project. 

Collaboration 

The working out of an approach involving increased identifica- 
tion of both scientists and community members with the culture 
of the other group can best be accomplished through a truly 
collaborative relationship between researchers and community 
members (Trimble, 1977; Fawcett, 1991). A great deal of prior 
research in ethnic communities has been almost exclusively 
directed by researchers, with community members expected to 
play a passive, or at most supportive, role. A major difficulty 
with this approach is that problems are often poorly defined, 
since they do not consider the real conditions of the community 
and thus are consequently of little help to the community. Fur- 
thermore, unless the community context, including especially 
the cultural context, is understood, research is likely to arrive at 
incomplete, if not erroneous, conclusions. For example, the study 
of health care utilization patterns in a certain community can 
only be understood in light of traditional beliefs about health 
and illness. 

Collaboration with community members, then, must begin 
early in the research process and include problem definition to 
ensure that the research is relevant to the community and well 
conceived scientifically. Methodological issues must also be 
addressed collaboratively to ensure that local values and customs 
are followed. A study that includes household interviews, for 
instance, would not be well received in a community where it 
is considered impolite for a stranger to approach one's house. 
Additionally, there may be certain topics that are culturally inap- 
propriate to ask about, and sensitive ways of collecting data 
must be agreed upon. 

Early collaboration will usually uncover certain constraints 
in the community that could affect the feasibility of proposed 
research. In most communities there are points of resistance that 
need to be anticipated and worked through collectively. These 
could entail contacting key persons within the community who 



124 



must sanction the research, or certain structural constraints such 
as upcoming elections, religious holidays, and the like. Besides 
constraints, there may be resources in the community that can 
be accessed to assist in the research. In the past, many ethnic 
communities have been treated as if they cannot handle their 
own problems and that only someone from the outside is capable 
of doing so. If a problem exists in a community, it is quite likely 
that there is already someone who has at least recognized it if 
not made some efforts to alleviate it. Bypassing these existing 
efforts has often led to strong feelings of resentment by local 
people. In general, extensive discussions before any research is 
conducted in a community will have high payoff in the end. If 
the researcher is aware of the research history of the community, 
the general attitudes of community members toward research 
efforts, and where difficulty may be encountered, the entire pro- 
cess will progress more smoothly. 

An additional benefit of early collaboration is the f amiliariza- 

J u N *» 

tion of local community members with the demands of research 
and providing an understanding of why certain activities and 
procedures are being proposed. Lacking information the commu- 
nity will be less likely to support the research effort. There is 
always the possibility that local people, once they have an under- 
standing of the research, can suggest ways in which the research 
can be altered to provide an even better design or methodology. 

Characteristics of the Successful 
Cross-Cultural Researcher 

Clearly cross-cultural research places high demands on those 
who become involved. There are many characteristics that, while 
common to all research, take on added importance in the cross- 
cultural setting. Perhaps the most important of these is the ability 
to continually monitor one's own cultural boundaries and to 
see how these may be obscuring a full understanding of the 
community perspective. Related to this self -insight is the willing- 
ness to extend one's own cultural boundaries to include an in- 
depth understanding and appreciation of the cultural values, 
beliefs, and traditions of the community. It should be recognized 



125 






that the process of achieving this understanding is a lengthy 
one, and one that is ongoing throughout the course of the 
research project. 

The need for collaboration between the community and the 
researcher has been made evident. Within this process the 
researcher needs to call upon skills of negotiation and compro- 
mise. There is always the tendency to push for rigorous science 
and to not recognize that this may not always be possible. In fact, 
this rigidity may prevent the seeing of alternatives embedded 
in the cultural milieu that eventually could produce a better 
understanding of the problem. Flexibility, then, is another hall- 
mark of the successful cross-cultural researcher. 

The potential for changing conditions that impact the course 
of research is extremely high in ethnic communities. The success- 
ful researcher, then, must be willing to constantly monitor the 
research project and become personally involved at the field site. 
It is not enough to leave the field work to others and assume 
that the original conditions will continue to hold. Along with 
the willingness to monitor, the researcher must have a great deal 
of endurance. Changing conditions may require modification of 
the research plan, a cycle that may be repeated often over the 
course of a project. At times it may be tempting to terminate 
the project due to the enormous energy required to maintain a 
scientifically respectable piece of work. Endurance, however, 
will not only see the project through but will establish trust 
between the researcher and community. Community people 
have struggled with social problems for years, if not decades or 
centuries, and there is an appreciation of those who are willing 
to persist with them and see a problem through. 

Patience and a tolerance for ambiguity will also serve the 
researcher well. The political and decision-making processes in 
many ethnic communities are often complex, and their inner 
workings are not always apparent to someone not fully knowl- 
edgeable of the community. In some places decisions are made 
by consensus, a time-consuming process that requires that any- 
one who is interested in a problem must have the opportunity 
for input. This often occurs in informal settings that are not 
accessible to the researcher but at some future point may be 



126 



reflected in a more formal arena such as a community meeting. 
Deciding when all interested parties have had their say and 
when it is appropriate to come to a consensus agreement takes 
a great deal of sensitivity and insight. It is often appropriate to 
consult with community collaborators to determine when it is 
all right to proceed with certain aspects of the research. 

There truly is no substitute for experience when working 
cross-culturally. A proven track record is vital in convincing the 
community that the researcher is there for the "long haul" and 
will be responsive to the cultural context. The researcher contem- 
plating cross-cultural work for the first time should be willing 
to seek advice and validation not only from respected members 
of the community but also from other researchers who have had 
experience in the community. 

Conclusion 






Approaches to cross-cultural research that assume an adversarial 
stance between researchers and members of an ethnic community 
may be adding an unnecessary burden and conflict to such work. 
Scientists need to increase their identification with the cultures 
of the communities in which they work, and community mem- 
bers need to increase their identification with the culture of sci- 
ence. The needs of the culture of science and ethnic cultures can 
be accommodated and in fact can work synergistically in the 
pursuit of knowledge and problem solution. Collaborative work, 
although time-consuming, can add immeasurably to the work 
of research and will help avoid conflict that detracts from such 
work. Effective cross-cultural research is as much a philosophy 
and frame of mind as it is a series of techniques. 

References 

Berry, J. Introduction to methodology. In: Triandis, H. and Berry, J., eds. Hand- 
book of Cross-Cultural Psychology, Vol. 2, Boston: Allyn and Bacon, 1980, 
pp. 1-28. 

Fawcett, S. Some values guiding community research and action. Journal of 
Applied Behavior Analysis, 4:621-636, 1991. 



127 



Gilbert, J. The anthropologist as alcohologist: Qualitative perspectives and 
methods in alcohol research. The International Journal of the Addictions, 
25,(2A):127-148, 1990. 

Goodenough, W. Ethnographic field techniques. In: Triandis, H. and Berry, J., 
eds. Handbook of Cross-Cultural Psychology, Vol.2, Boston: Allyn and Bacon, 
1990, pp. 1-28. 

Manson, S., ed. American Indian and Alaska Native Mental Health Research, 2(3): 
entire issue, 1989. 

Oetting, E., and Beauvais, F. Orthogonal cultural identification theory: The 
cultural identification of minority adolescents. International Journal of the 
Addictions, 25:655-685, 1990. 

Ramirez, M. Psychology of the Americas: Mestizo perspectives on personality 
and mental health (Ch. 6). New York: Pergamon Press, 1983. 

Trimble, J. The sojourner in the American Indian community: Methodological 
concerns and issues. Journal of Social Issues, 33:159-174, 1977. 

Trimble, J. Putting the ethic to work: Applying social-psychological principles 
in cross-cultural settings. In: Bond, M., ed. The Cross-Cultural Challenge to 
Social Psychology, Newbury Park, CA: Sage Publications, 1988. 



128 



7 

Methodological Issues in 

Conducting Alcohol Abuse 

Prevention Research in 

Ethnic Communities 

Steven P. Schinke and Kristin C. Cole 



Introduction 

As the science of alcohol and other drug abuse prevention has 
emerged and developed, investigators have devoted increasing 
attention to issues of cultural sensitivity (Brislin, et al., 1973; 
Hofstede, 1980; Marin, et al., 1992; Rogers, 1983; Teahan, 1987, 
1988; Uba, 1992; Welte and Barnes, 1987). This attention is due, 
in part, to the realization that the frequency of alcohol and other 
drug abuse problems varies with their particular cultural context 
(Peters, Oetting, and Edwards, 1992; Schinke, et al., 1990; Schinke, 
Botvin, and Orlandi, 1991). That realization, in turn, follows 
trends in mental health research toward recognition of the role 
culture plays in the onset, remediation, and prevention of many 
mental disorders and problems (Rogler, 1989; Rogler, et al., 1987; 
Rogler, Malgady, and Rodriguez, 1989; Schinke, et al, 1990). 



Research reported in this chapter was supported by the National Institute on 
Alcohol Abuse and Alcoholism, grant number AA08615. 






** 



. 



129 



Admittedly, cultural factors have long been addressed to 
some degree in alcohol and other drug abuse prevention 
research. As evidence accumulated showing that ethnic-racial 
groups differ in terms of their cultural values, norms, expectan- 
cies, and attitudes (Landrine and Klonoff, 1992), investigators 
began to explore targeted culture-specific interventions for alco- 
hol abuse and other problems. But only recently have investiga- 
tors begun to fully appreciate how cultural factors relate to suc- 
cessful treatment and prevention outcomes. That appreciation 
stems in part from the largely undistinguished record of past 
alcohol abuse prevention efforts to delay the onset of alcohol 
use and misuse among their target populations — particularly 
among members of ethnic-racial and other culturally defined 
groups (Moskowitz, 1989). 

Among those factors responsible for undermining the effects 
of prevention programs in reducing the incidence of alcohol 
abuse is the scant attention paid to the etiology of alcohol use. 
The limited understanding of this etiology has complicated the 
selection of the cultural variables to be included in the design and 
evaluation of treatment and prevention programs. Consequently, 
substance abuse researchers are beginning to tailor programs 
aimed at alcohol and other drug abuse problems for the cultural 
contexts in which those problems occur and, what is even more 
important, to determine the contexts in which those problems 
are best understood, treated, and prevented. 

This chapter will discuss and illustrate methodological issues 
in conducting culturally sensitive alcohol abuse prevention 
research in ethnic-racial communities by citing the authors' own 
research experiences. Although the studies cited target Native 
American youth, the principles and skills drawn from these stud- 
ies apply equally to work with other ethnic-racial groups, or 
with any other specific groups, including youths as a demo- 
graphic group, persons with disabilities, older persons, and other 
particular populations. The chapter opens by considering the 
issues of cultural sensitivity and cultural competence. Next, we 
present in detail steps for achieving that sensitivity and compe- 
tence. We then devote our attention to reviewing the application 
of culturally sensitive methodology in the practice of evaluating 
programs to prevent alcohol and other drug abuse. 



130 



Cultural Sensitivity and Cultural 
Competence 

To borrow Marin's (1992) definition, a culturally appropriate 
intervention is a set of behavior-change strategies that is based 
on the cultural values of the target group, reflects their attitudes, 
expectancies, and norms regarding a particular behavior, and 
components reflect the target group's behavioral preferences and 
expectations. Intervention strategies that do not correspond to 
these cultural values may fail. Because some cultures abuse alco- 
hol more than others, these considerations are particularly ger- 
mane when investigating alcohol abuse, alcohol abuse patterns, 
and ways to prevent alcohol abuse. 

No matter what their own ethnic-racial background, investi- 
gators must attend carefully to issues of cultural sensitivity if 
they wish to conduct culturally competent research. Investigators Jj 



K 






cannot assume they possess cultural sensitivity because they 



* 



have the same ethnic-racial background as the target group; 
shared cultural identity does not guarantee facility in dealing 
with a particular group's day-to-day realities. Considerable 
diversity exists among the members of ethnic-racial groups, 
depending upon their geographic origin, income level, accultura- 
tion, religion, and other factors. There is no guarantee, for exam- 
ple, that a Navajo born and educated in Chicago would be cultur- 
ally sensitive in work with Navajo farmers in Arizona. 

Investigators from a wholly different culture may find it 
especially difficult to establish cultural sensitivity. But it is neces- 
sary. Moving across cultures — cross-cultural research — is 
unavoidable when conducting studies in today's society. In the 
United States, investigators can expect to work with a broad 
range of ethnic-racial groups, and within each group they will 
find significant diversity. In New York City, for example, His- 
panic American can mean, in order of the proportion of the 
population represented, Puerto Rican, Dominican, Cuban, South 
American, and Mexican American. These groups of Hispanic 
Americans vary greatly, and culturally sensitive investigators 
will address each group with these variations in mind. Each 



131 



target group is unique, and though it may share characteristics 
with other groups of the same ethnic-racial makeup, the investi- 
gator must develop sensitivity to that particular group and its 
members. Investigators should not assume that past experience 
or her or his own ethnic-racial identity will bridge the gap. 

By definition, ' 'cultural sensitivity 7 ' is an awareness of one's 
own and others' cultures. Another term used throughout this 
chapter is "cultural competence." According to Orlandi (1992), 
who is writing of the substance abuse prevention field, cultural 
competence includes cognitive and affective abilities that allow 
individuals to be knowledgeable, committed to change, and hig- 
hly skilled at working constructively with members of an ethnic- 
racial minority group. Thus, cultural competence refers to a set 
of skills that allow individuals to increase their understanding 
and appreciation of cultural differences and similarities. Whereas 
developing cultural sensitivity is a kind of consciousness raising, 
cultural competence requires learning the skills that facilitate 
working with a particular group in a way that leads toward 
constructive change. 

Achieving Cultural Sensitivity and 
Cultural Competence 

The great challenge for prevention researchers in the alcohol 
abuse field is to achieve not only cultural sensitivity but also the 
cultural competence required for the development and evalua- 
tion of responsive intervention programs and scientific investiga- 
tions. To begin the process of achieving cultural competence, 
investigators should become familiar with the target culture. 
Reading about the culture, visiting, watching, and listening to 
members of the culture, and asking questions about the culture 
are all ways to increase familiarity with a target group. As investi- 
gators gather information, they must strive to remain descriptive, 
rather than judgmental, about the target culture. Maintaining 
objectivity is of the utmost importance. 

Yet, despite the importance of thinking objectively and 
descriptively, research projects are not anthropological exercises. 
Investigators deliberately manipulate variables within the target 



132 



setting. Without the community's trust and approval, such 
manipulation may be met with suspicion or antagonism. Collabo- 
rating with members of the target community is therefore espe- 
cially important in cross-cultural research. This collaboration is 
not superficial. Through it, the research team derives the insights, 
access, and credibility necessary for a successful study. 

Ideally, investigators will gain the target culture's trust before 
initiating their involvement in the study. If members of the com- 
munity believe in the integrity and sincerity of the project, they 
will be more likely to commit their time. With proper credentials, 
community members can collaborate in all levels of the 
research — as writers, co-principal investigators, project manag- 
ers, interveners, and administrative aides. This collaboration can 
enhance a study's credibility. Working as peers with members 
of the community on a research project will also increase the 
likelihood of honest feedback. In our experience, when members 
of the community are on the project's payroll, they are more apt 
to invest themselves in and care about the integrity of the project. 

Focus groups of community representatives may also 
enhance the cultural accuracy of the project and may reveal data 
necessary for proactive planning. Admittedly, focus group data 
can be imperfect. Random selection of a representative sample 
of community members will help guard against biased data, as 
will multiple sessions with different samples. Although investi- 
gators can never rely solely on focus group data, they should 
conduct focus groups during the developmental phase of a study 
and, ideally, also during the proposal writing phase. 

Besides involving the community in the research project, the 
investigators should involve themselves directly in the life of 
the community. Investigators can learn a great deal through 
actively immersing themselves in the target culture. For example, 
while studying alcohol abuse prevention among Native Ameri- 
cans, investigators can take part, at least as observers, in spirit 
dancing, powwows, and other traditional ceremonies that will 
help them learn about this culture from the inside. 

Optimally, investigators will verify at least some of their 
ideas with the target culture. Showing the study's variables and 
procedures to members of the community who have expertise 



133 



! 



in the area may elicit valuable criticism. Feedback from collabo- 
rating members of the target culture will help investigators 
revise — to the extent that revision does not jeopardize the sci- 
ence — and investigators may then resubmit their work until con- 
sensus is achieved. This negotiation process can clarify the pur- 
poses of the research for the investigators as well as for the 
community. It will help to prevent misunderstandings and add 
depth to the study's content. Too much compromise on an inter- 
vention, however, will make it difficult to manage. Investigators 
will need to determine the extent to which the intervention can 
incorporate individual differences without losing its applicabil- 
ity. Indeed, investigators may find it necessary to sacrifice speci- 
ficity and individual relevance to achieve generalizability to the 
larger community (Marin, 1992). Investigators, for example, may 
be forced to incorporate only those cultural values, attitudes, 
and norms that have shown intergroup variance and to disregard 
intragroup differences. 

Although investigators are normally unprepared to establish 
a fully functioning alcohol abuse prevention program that will 
continue after the study is completed, a research project can 
offer other advantages for the community. There are economic 
benefits. Members of the community will be hired for the project 
staff, preferably in a field office (Schinke, Botvin, and Orlandi, 
1991). A sense of ownership can be inspired by investigators 
who have made a sincere effort to involve the community. 
Toward that end, investigators can share materials from the 
study with as many community members as possible, and use 
traditional language from the community for curricula or other 
study materials (Schinke and Orlandi, 1991). 

Culturally Sensitive Methodology 
in Practice 

Many researchers have expertise in specific areas of their field 
and are eager to apply that expertise in new settings. Much of 
the time, such a process is mutually beneficial, but clinging to 
a research idea when it means disregarding community needs 
is often unproductive. The culturally competent investigator will 



134 



consider community needs and perspectives before adopting a 
research agenda. Such community input may alter the research 
focus. While that change may seem unsettling to the researcher, 
the benefits of conducting research that the community identifies 
as necessary are obvious. An intervention strategy that is per- 
ceived by the members of the target culture to be relevant and 
familiar is more likely to promote the behavior change being 
advocated than an irrelevant, foreign intervention strategy. The 
strategy that a community prefers, however, may be one an 
investigator knows to be relatively ineffective. Investigators 
should balance their responsiveness to the community with their 
own expertise in the area of inquiry. It is a delicate balance. 
During our work with the prevention of alcohol and other drug 
use among Native American youth, we have developed proce- 
dures for achieving this balance that may be useful with other 
target groups as well. 



Americans, we have made use of two strategies to recruit commu- 
nity sites for research participation. Those studies developed and 
tested skills and family interventions to prevent alcohol abuse 
among Native American youth. In the first strategy, we conduct 
mass mailings to Native American community organizations and 
agency staff, including social workers, counselors, nurses, and 
allied human services and health professionals who are associ- 
ated with alcohol prevention and treatment. Following the initial 
contact, we arrange for staff presentations, along with question- 
and-answer sessions on the nature of the study, the intervention 
approach, and agency staff responsibilities. If staff responds posi- 
tively, we then seek adrninistrative clearance from appropriate 
agency officials. 

In the second recruitment strategy, we begin by contacting 
Native American community organization administrators to 
inform them of the study and obtain their participation. Once 
administrators agree to collaborate, the participation of their staff 
invariably follows. This second strategy is efficient and usually 
effective, though at times an enthusiastic administrator may 



Recruitment and Training 

In past alcohol preventive intervention studies with Native 






135 



mandate the involvement of staff members who have little or 
no interest in the study. 

These two strategies differ by whom we initially contact. In 
the first strategy, we contact and attempt to recruit staff who 
will presumably be involved in delivering the intervention (i.e., 
teachers, social workers). In the second strategy, we contact and 
attempt to receive from administrators or leaders of those staffs 
permission to recruit their staff. Although the first recruitment 
strategy offers some advantages, we found it less effective than 
the second when sampling a specific at-risk youth population. 
The difficulties we experienced in recruiting Native American 
staff without first obtaining the permission of tribal leaders made 
clear to us the merits of the second strategy. We have nevertheless 
capitalized in our research on the advantages of the first strategy 
r . by putting a premium on the voluntary support of individual 

staff, rather than relying solely upon administrative mandate. 

Once the targeted Native American sites have agreed to par- 
ticipate in the study, our next step is to recruit specific personnel 
within the sites for intervention delivery positions. Research 
suggests that indigenous health education providers and slightly 
older peers are effective delivery agents of skills interventions 
(Botvin, et al, 1983; Hurd, et al., 1980; Luepker, et al, 1983; 
Murray and Perry, 1985). 

Our studies have revealed both advantages and disadvan- 
tages in using peer leaders for alcohol preventive intervention 
delivery. Although in some cultures peer leaders enjoy higher 
credibility than professional staff regarding lifestyle issues, peer 
leaders lack the professional's skills in intervention delivery and 
management. Moreover, research with Native American youth 
populations reveals their preference for adults as leaders, thanks 
to the genuine respect for elders within the Native American 
culture. Yet other data suggest that slightly older peers are more 
effective than adults in presenting substance use prevention pro- 
grams (Botvin, et al., 1990; Perry, 1989). To reconcile these various 
factors, we employ a combination of adult and peer leaders, with 
adult leaders as the primary delivery agents. 

We conduct on-site community staff training in workshops 
led by our staff. Workshops orient Native American community 



136 



staff to our intervention rationale, describe intervention materi- 
als, provide a session-by-session analysis of interventions, and 
allow behavioral rehearsals of skills for delivering the interven- 
tion. In practice situations, community staff lead groups to simu- 
late an intervention delivery experience. Besides providing staff 
members with substantive material, workshops generate enthu- 
siasm and commitment among staff. Native Americans selected 
as peer leaders also attend training workshops conducted by 
our staff. Paralleling the on-site staff workshops, peer leader 
training provides an overview of the intervention, emphasizes 
rehearsals and practices, and allows time for discussion to clarify 
leader roles and responsibilities. 

These staff training procedures have contributed to positive 
collaborative relationships between ourselves and the targeted 
Native American communities. In our own experience with 
developing and testing skills and family interventions to prevent 
alcohol abuse among youth, when members of the target culture g N 2 

act as intervention deliverers they are more likely to feel a sense of 
ownership toward the study. Using indigenous staff as delivery 
agents can also enhance the intervention's accessibility within 
the target culture (O'Sullivan and Lasso, 1992). 

The intervention must be meaningful for the target commu- 
nity. In this case, because the intervention targeted alcohol abuse 
among Native Americans, recognizing drinking patterns unique 
to Native American culture was essential. Study variables should 
involve and reflect the target culture, and not be based solely 
on the norms of other ethnic /racial cultures or the majority 
culture. The language of the intervention must similarly reflect 
the language of the culture. The descriptors of our studies are 
modified with the guidance of the participating Native American 
community staff, to be meaningful to the target culture in all 
phases of the intervention. 

Yet despite such cultural specificity, maintaining generaliz- 
ability is also important. If a study is too specific, so that it 
pertains to only one tribe living in one area, the experiences and 
results attained from the study will not be of help to other tribes 
with similar needs or to other researchers seeking to benefit from 
the work of prior studies. 



137 






Study Approach 

In the first year, working with members of our target Native 
American communities, we develop study interventions to pre- 
vent alcohol and other drug abuse among the youth. Once we 
have a draft version of study curricula, we conduct multiple 
focus groups, one with a random sample of Native American 
youth counselors, another of youths, and a third of their parents. 
These focus groups examine study interventions for their cultural 
responsiveness, interest, and logistics. Focus group feedback 
helps us to test and revise study interventions. We continually 
improve the interventions until focus group data indicate that 
each intervention is ready for field testing. Native American staff 
from the community assist with the conducting, recording, and 
interpretation of focus groups. 

To maximize the effectiveness of the interventions, we have 
employed a combination of our own staff, Native American 
agency providers, and slightly older peers. As primary interven- 
tion providers, staff employed by collaborating Native American 
community organizations can help to supply focus groups with 
subjects, organize intervention activities, help youths in identify- 
ing appropriate goals for preventive intervention, provide 
youths with positive reinforcement, organize behavior rehears- 
als, maintain order, and coordinate peer leaders' activities. 
Native American peer leaders can serve as discussion leaders 
and role models, demonstrate behavioral skills, and organize 
role-playing sessions. 

Most intervention studies require a no-intervention control 
group. In some communities, such a group may be considered 
unacceptable or unethical, particularly in an alcohol and other 
drug abuse prevention program. Ethnic /racial groups who feel 
exploited by the majority culture may interpret an outside inves- 
tigation as invasive, or as a detached laboratory experiment to 
satisfy the institution's curiosity rather than to help their commu- 
nity. This distrust can increase when they learn that some mem- 
bers of their culture who participate in the research will receive 
no intervention. Our research with Native American people has 
sensitized us to their problems with no-intervention and control 



138 



groups. Unless we are persuaded that such groups are essential, 
we are reluctant to randomly assign Native Americans to an 
arm of the study that we know will not provide an effective 
intervention. Yet, despite this community pressure, conducting 
an intervention without the proper scientific conditions renders 
the study meaningless. We typically offer control condition sub- 
jects either a different, unrelated intervention or — once we have 
completed the formal study period — the same intervention that 
the other groups have received. The control condition subjects 
become members of what we call the wait-list control group. In 
these arrangements, as in any arrangement a researcher may 
work out, what is essential is the right balance between scientific 
needs and goals and the target culture's concerns. 

Some studies can avoid using a no-treatment control group 
altogether. Studies that are refining or testing existing interven- 
tions may use comparison groups that are themselves exposed 
to some intervention instead of using no-intervention control 
groups. For example, in a study aimed at reducing substance 
abuse risks among Native American adolescents through an 
interactive computer intervention, we used a randomized clinical 
trial design with repeated measures. Subjects in one group 
received the intervention via interactive computer, and subjects 
in the second group received the same material in a group inter- 
vention. Although the absence of a nonintervention control arm 
precluded comparisons of either intervention against no inter- 
vention, the design allowed the testing of the relative merits of 
two intervention strategies. 

Such a design is feasible when investigators have empirical 
reason to believe that any intervention is preferable to no inter- 
vention — based on prior research data, for example — and when 
statistical power calculations indicate that the design will permit 
the discovery of relatively small differences between groups that 
received variations on the same intervention. 

A related concern in cross-cultural research is the issue of 
randomization. True experimental designs require a random 
sampling of the community for study participation. As a result, 
some of the community will not take part in the study at all, or 
may not receive intervention. Community members who are 



139 






unaware of the reasons for randomization in scientific studies 
may object to their exclusion from the study. At the very outset, 
investigators must explain clearly to the target community what 
they can and cannot expect from the planned study. These mat- 
ters have to be spelled out in detail and should be repeated more 
than once. We have also found it helpful to point out to control 
group members the benefits of participating in the research 
despite their not receiving intervention. These benefits include 
contributing to the prevention of alcohol abuse among Native 
Americans, and discovering their own risks for alcohol abuse. In 
our own experience conducting prevention research with Native 
American populations, we have been successful with randomiza- 
tion. 

Measurement 

Selecting sound measurement instruments is frequently prob- 
lematic when working with ethnic-racial communities. Most 
measures that exist for study phenomena are not sensitive to 
particular ethnic-racial or other cultural groups. Few good 
options exist for resolving this dilemma. Using a widely accepted 
measure that does not have normative data on the target group 
is one option; developing a new measure is another. Developing 
a culturally sensitive measurement, however, can comprise a 
research project on its own — unless the investigator proposes 
time in the study for that process. 

In our own research experiences, we have formatively and 
psychometrically tested outcome measurement instruments for 
use in quantifying the effects of alcohol abuse prevention pro- 
grams with specific cultural groups. Formative testing with focus 
groups of target subjects refines and adds precision to each mea- 
surement instrument and scale. Unquestionably, focus group 
data can be marred by participants' biases. Investigators too 
can prejudice focus group data by asking leading questions. 
Conducting multiple sessions with a random selection of com- 
munity participants helps guard against biases. 

Content for focus groups comes from our own and others' 
questionnaires on alcohol abuse and related behavioral risks. 



140 



V I 



Addressing issues of age-, gender-, and cultural-responsiveness, 
focus groups involve subjects representing both genders, sub- 
stantial ethnic-racial and majority culture groups, and urban and 
suburban settings within the study region. Leaders of measure- 
ment focus groups follow guidelines for convening, executing, 
and recording the sessions (Krueger, 1988). Guided by conven- 
tional procedures, we analyze and interpret focus group data 
(Patton, 1980). 

Once focus group data have informed changes to the format, 
ordering, and language of each instrument, we psychometrically 
test the measures. Psychometric tests involve stratified samples 
of another group of subjects from each gender, and majority 
culture group (if relevant), and urban and suburban community 
site. Psychometric tests determine the reliability of each instru- 
ment and scale through test-retest and split-half procedures. 
Whenever feasible, we cross-validate our measures' scores with 
data from parallel instruments. For example, data from a new 
or adapted measure can be compared with findings from extant 
measures on the same variables. 

Ownership 

In a study to prevent alcohol and other drug use among Native 
Americans in the Pacific Northwest, we used the name "La Quee 
Biel" as the title of the curricula. "La Quee Biel" means to cure 
or to prevent in the Coast Salish language. Based on our conversa- 
tions with community members, it was our impression that titling 
the curricula with the study culture's language helped to build 
a sense of ownership among the community. 

When the alcohol and other drug abuse prevention project 
expired, we left behind tangible goods for the community. Com- 
munity treatment manuals, curricula, posters, videotapes, and 
T-shirts, together with articles reporting the results of the study, 
were made available to the community. As a result of the positive 
findings from the intervention, some Native American field staff 
recruited from within the target reservations were eager to con- 
tinue using the materials. Their three years of experience deliver- 
ing the intervention to prevent alcohol and other drug use gave 
them the necessary experience to continue doing so. Other Native 



141 






American staff had learned through our study relatively sophisti- 
cated data gathering and data entry procedures. Two of these 
staff were able to obtain data entry jobs with other local 
research efforts. 

We were fortunate to have developed and maintained a good 
relationship with the target community in the above study. Cer- 
tainly, we owe some of that success to our commitment to involv- 
ing the Native American community in the study to the greatest 
extent possible. Other investigators can achieve harmonious rela- 
tionships with communities by similarly encouraging commu- 
nity ownership. Investigators should, however, beware of prom- 
ising anything to a community before they are absolutely certain 
that the promise can be kept. 

Possible Risks 

Establishing cultural competence is difficult, but the rewards for 
attempting to meet the challenge, however imperfectly, are great. 
Investigators who develop proposals, ideas, interventions, mea- 
surement instruments, and sampling procedures that are cultur- 
ally sensitive and culturally competent set themselves apart from 
their peers. It will often be necessary to strike a compromise 
between a study's cultural responsiveness and its scientific integ- 
rity. Cultural responsiveness may be particularly necessary 
because of the need to attract, engage, and impact members of 
an ethnic-racial group who have not been responsive to interven- 
tions in the past. But without a rigorous design and evaluation 
strategy, even the most promising prevention program cannot 
be found effective and therefore recommended for program- 
matic use. 

An honest presentation of the reasons for a particular com- 
promise in the study proposal will allow reviewers to follow 
the investigators' decision-making process. Such evidence that 
decisions have been carefully considered can be persuasive to 
reviewers. Proposals that lack cultural sensitivity and cultural 
competence are not likely to receive funding. What is more 
important, intervention programs that lack such sensitivity and 
competence may be less effective in reducing alcohol abuse 
(Moskowitz, 1989; Marin, 1992; Flay, 1986). 



142 



\ 



Despite the benefits of conducting culturally sensitive 
research, investigators devoted to such research expose them- 
selves to risks. Some ethnic-racial groups may view the investiga- 
tors as opportunists. Target group members may suppose that 
the investigator's interest in them is prompted by the need for 
funding rather than by a sincere desire to improve the communi- 
ty's well-being. At times, it may be appropriate to say to members 
of the target group that, while naturally the investigators have 
an interest in getting financial support, funding for the project 
will mean that the community has a real opportunity for educa- 
tion and change. 

It is also possible for the community to misinterpret the 
purpose of the research. Some members may confuse research 
with actual service delivery. This can lead to trouble when the 
research project expires, as well as during the project's course. 
Carefully reviewing the grant proposal with key community u 

figures can guard against this misconception. 

Other risks concern letters of collaboration. Some communi- 
ties may consider a request for their letter of collaboration as 
tantamount to the receipt of a grant. Community leaders may 
spend considerable time weighing their response to the investiga- 
tor's request without understanding that their willingness to 
collaborate does not guarantee that the research project will be 
funded. Wise investigators will make it very clear to the target 
group what the letter of collaboration is and what it is not. They 
may thereby lessen ill-feeling in a disappointed community if 
the project is not funded. 

As with all research programs, the limited success or outright 
failure of an alcohol abuse prevention program for members of 
an ethnic-racial group entails risks. If the program fails to do 
what was hoped for, the investigator will, at the least, be made 
to feel embarrassed. Of more serious concern, a lack of positive 
findings may lower the investigator's status within the target 
culture and leave members of that culture hesitant to participate 
in other studies. Individuals may lose their faith in research 
programs altogether if even a study that has been carefully tai- 
lored to their particular culture yields no tangible results. 



143 



Conclusion 

This chapter deals with methodological issues in conducting 
culturally sensitive alcohol abuse prevention research in ethnic- 
racial communities. The chapter reviews issues of cultural sensi- 
tivity and cultural competence and proposes steps to achieve 
such sensitivity and competence. Most of the chapter is con- 
cerned with procedures for implementing culturally sensitive 
methodology in evaluating programs to prevent alcohol and 
other drug abuse among cultural groups. Despite the chapter's 
emphasis on substance abuse prevention research among Native 
American youth, the principles and skills illustrated by that 
research apply to research with other ethnic-racial groups and 
with other culturally defined groups as well. 

Conducting culturally sensitive research has several benefits. 
It can be more relevant, meaningful, and important than research 
that pays only cursory attention to cultural nuance. Researchers 
who sensitively and accurately assess cultural variables can have 
greater confidence that study results were due to the intervention 
itself. Conversely, researchers whose methods ignore or mini- 
mize cultural issues may reach erroneous conclusions. 

In the United States today, there are thousands of individual 
cultural groups, with many more groups — and increasingly het- 
erogeneous ones — nascent as the country's population grows 
and diversifies. Notions of culture and of cultural groups are 
changing rapidly as population demographics shift. Soon, for 
example, ethnic-racial groups that once comprised segments will 
gain dominance in population percentages and numbers. 
Because patterns of alcohol use and other substance use will 
continue to vary by cultural group, investigators no longer have 
the option of developing universally applicable methods for 
building, testing, and disseminating preventive intervention 
strategies. To avoid the implications of cultural variables is to 
suffer the consequences of investigations that neither address 
those variables nor impact positively the target population. 

This chapter is a first step in helping investigators not only 
to understand the nature of cultural variables in research design, 
but also to respond to cultural issues with predictably sensitive 



144 



and effective designs, methods, and procedures. Once we achieve 
that predictability, we greatly increase the likelihood of moving 
the field of alcohol abuse prevention forward by creating and 
building upon solid empirical data that realistically reflect the 
everyday context of the groups we are targeting. To engage in 
that planful forward movement is to further the scientific process 
that has so successfully laid the foundation upon which the field 
of prevention is building. Perhaps the guidelines offered in this 
chapter will in some measure promote the application of tested 
scientific principles in future efforts to investigate alcohol abuse 
prevention programs within a cultural context. 

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. 



8 



Methods to Create and 
Sustain Cross-Cultural 
Prevention Research 
Partnerships: The NAPPASA 
Project's American Indian- 
Anglo American Example 

Jon Rolf 



Introduction 

Community-based prevention research with youth in high-risk 
environments is a very complex undertaking. It often requires a 
collaborative multi-disciplinary project team in order to develop, 
implement, and evaluate its preventive interventions. Unfortu- 
nately, prevention researchers are rarely members of the commu- 
nities in which they conduct prevention programs for at-risk 



The research reported here involves the American Indian Prevention Project on 
AIDS and Substance Abuse which was supported by an NIAAA Prevention 
Research Branch grant (ROl AA08578, J. Rolf, P.I.) with additional support by 
the Maternal and Child Health Bureau Training Grant to the Department of MCH, 
Johns Hopkins University. The opinions expressed here are those of the author 
and do not necessarily reflect those of any other person or group including the 
Indian Health Service. 






149 



youth. This is especially the case for some racial-ethnic commu- 
nities which have great need but do not have residents with all 
the requisite methodological skills to conduct prevention studies. 
It is possible for these communities to form productive preven- 
tion research partnerships with researchers from outside the 
community when the expected benefits clearly outweigh the 
risks of working with them. However, the research partnerships 
will fail if the outsiders are perceived to be culturally insensitive 
to local values, customs, and politics or whose short-term 
research agenda seems to take away more than it gives to the 
community. 

Prevention researchers who choose to work in a racial-ethnic 
community in which they do not live or share ethnic identities 
have unique lessons to share, given that no two communities 
have identical needs for prevention programming. This chapter 
describes the experiences of a prevention researcher who was 
invited to come into a racial-ethnic community in order to 
develop a new prevention project. It came to be known as the 
Native American Prevention Project on AIDS and Substance 
Abuse (NAPPASA), and the experience gained from forming 
prevention research partnerships with American Indian commu- 
nities in the Southwest is the substance of this report. Drawing 
on his personal experiences 1 , the author identifies several lessons 
and issues which help explain how the NAPPASA project's 
research partnerships were made and became productive. 
These thematic issues are: 

• Finding local leadership 

• Telling the project's origin story 

• Why us? — Why you? 

• Giving more than getting 

• Listening to what they have to say 

• Being there 

• Telling the prevention story through local media 
Before describing each of these in detail, some background 

information should be provided concerning: (1) the project's 
American Indian community contexts in Arizona relevant to 
risks for alcohol problems and HIV infections, (2) the prevention 
needs of these American Indian communities, and (3) an over- 
view of the NAPPASA project's research design and programs. 



150 



v 



An Overview of the Northern Arizona 
American Indian Populations and Some 
of their Prevention Needs 

Were the author an American Indian, he might describe the 
American Indian communities in northern Arizona with different 
words than are used here. Were he Navajo, the words about this 
tribe and its health needs would certainly be different. Instead, 
the prose of an Anglo-American academic prevention researcher 
is used here to present background data used to justify the choice 
of research partners and the communities' motivations to seek 
such partnerships. 

The NAPPASA project has been developed with a number of 
American Indian and ethnically mixed communities in northern 
Arizona. Most work has been with Navajo communities. The 
Navajo Nation is one of the principal tribes of American Indians 
now residing in northern Arizona. Other local tribes include the 5 N JJ 

Hopi, Southern Paiute, Havasupai, Walapai, White Mountain 
and Yavapai Apache, and the Yavapai. Most live on reservations, 
and the Hopi reservation is even embedded within the lands of 
the Navajo Reservation. The Navajo are the most numerous 
locally, and the Navajo Nation is also one of the two largest 
tribes in the United States. Its members comprise about one fifth 
of the United States American Indian population. Most Navajo 
(about 160,000 to 180,000) live on their reservation, which occu- 
pies 25,000 square miles of northern Arizona, northwestern New 
Mexico, and southern Utah. Many other Navajo and persons 
from other tribes live in border towns adjacent to the reservation 
(Coulehan, et al, 1983). It is estimated that 65,000 Navajo live 
outside the reservation in adjacent border towns such as Flagstaff 
and Winslow, Arizona, as well as in distant cities such as Los 
Angeles and Phoenix. 

Navajo traditional culture involves pastoralism and living in 
scattered homesteads rather than large groups. Even today, a 
great many Navajo live in solitary or clustered traditional home- 
steads across their reservation. However, Navajo philosophy 
embraces change wherever it can be incorporated into Navajo 
tradition. Consequently, in recent decades the Navajo have 



151 



accepted all kinds of new employment patterns and lifestyles, 
even while maintaining strong linguistic and cultural traditions. 
Many of the Navajo living on or near the Navajo Nation Reserva- 
tion are bilingual. For a great many of the Navajo, their first 
language was Navajo or a mixture of Navajo and English. On 
and near the Navajo Reservation, Navajo is a very common 
language of daily discourse, although English is the primary 
language of instruction in the schools. 

Local Factors Which Impact Health. Important socioeco- 
nomic factors (including poverty, unemployment) and geo- 
graphic conditions (extreme rurality and distances between 
towns and health services) influence the health behavior of the 
Navajo, other American Indians and non- American Indians liv- 
ing in northern Arizona. Some of these factors can place certain 
sub-groups in the population at high risk for injury and disease. 
Among persons at risk are those who use or abuse alcohol and 
other drugs (AOD). These higher risk persons and other northern 
Arizona residents typically make long trips to towns across or 
bordering the reservation in order to access various commercial 
outlets, community services, and recreation facilities. On these 
long trips (often as drivers or passengers in the open truck beds 
of pickups), there are very high risks for traffic accidents. (In 
fact, recent reports (Caces, et al, 1992) show that alcohol-related 
mortality rates locally are among the highest in the United States.) 
For some people, these trips are also occasions for misuse of 
AOD. Under these conditions the traffic accidents are even more 
likely, as is the case for alcohol-related violence and opportunities 
for intimate contact with sexually transmitted diseases (STDs) 
and HIV carriers through unprotected sexual behavior. Local 
health service providers were very aware of such alcohol- and 
drug-related problems and mortality, and they were very 
receptive to developing new prevention partnerships which 
might address these risks. 

Northern Arizona's rural American Indian communities are 
not isolated from health problems such as HIV/ AIDS and abuse 
of injected drugs, which are usually thought to be mostly con- 
fined to urban areas. Northern Arizona's only methadone main- 
tenance clinic and its attendant population of injecting drug 



152 



users (IDUs) is located in Flagstaff, Arizona, which is the major 
commercial center serving the NAPPASA project's communities. 
These IDUs probably represented one of the earliest vectors for 
HIV transmission to local American Indian populations through 
the sharing of injecting needles and through sexual intercourse. 
In addition, the risks for HIV-transmitting sexual contacts with 
non-IDUs is heightened by a number of other geographic and 
economic factors in northern Arizona. Seasonal tourism is boom- 
ing, with tens of thousands of outsiders visiting the nearby Grand 
Canyon and attractions on the reservation. Many other outsiders 
pass through northern Arizona due to Interstate Highway 40's 
long-haul trucking depots, the Santa Fe Railroad's depots, and 
the Winslow, Arizona, prison's practice of holding in-transit 
extradited criminals in cells with local prisoners. Furthermore, 
northern Arizona American Indian residents are faced with high 
unemployment rates (as high as 40-50% for the Navajo; Yates, 
1987). This compels many Indian adolescents and adults to seek 
work in other cities such as in Southern Arizona, Texas, and 
California. 

In these cities the available low-paying jobs may limit them 
to living in urban locations where substance abuse and rates of 
HIV infection are much more prevalent (Coulehan, et al., 1983; 
May, 1986; Weibel-Orlando, 1987). Since ties to family and the 
reservation remain very strong, most of these dispersed workers 
return home several times a year for traditional ceremonies, 
recreation, and procreation, during which time HIV infections 
might be inadvertently brought back to local residents. 

Alcohol Morbidity and Mortality. Because the Navajo are 
a very large tribe with many contacts with the United States 
Indian Health Service (IHS) clinics and with tribal health services, 
considerable data about AOD use and abuse have been generated 
for study. These data show that alcohol abuse is an extensive 
problem requiring treatment and prevention programs (e.g., 
Andre, 1979; Bach and Bornstein, 1981; Topper, 1985; May, 1989, 
1986; May, Hymbaugh, Aase, and Samet, 1983). Age-adjusted 
alcohol-related morbidity and mortality rates among the Navajo 
far exceed rates for the general United States population: rates 
are fourfold higher for alcohol-related injuries, almost twofold 



153 



. 



for violence, almost threefold for alcohol-related illnesses, and 
twentyfold for alcohol-related deaths (Broudy and May, 1983; 
USIHS, 1984; Yates, 1987; May and Hymbaugh, 1989). May (1986) 
reports that the rates of indications of alcohol-related problems 
are also high. These indicators include arrests, suicides, and cases 
of fetal alcohol syndrome. Age-adjusted suicide (per 100,000) 
rates for calendar year 1987 are: 11.7 U.S. all races, 18.6 all IHS 
areas, 14.7 IHS Navajo area (see USIHS, 1991). 

Prevention Orientation of Local American Indian Commu- 
nities. A recent report on the health-risking behaviors and 
health problems of American Indians and Alaskan Natives pres- 
ents data that suggest that American Indian youth have a great 
need for prevention programs (Blum, et al., 1992). These authors 
reinforced the pre-existing belief that there is also a great need 
for culturally and behaviorally oriented studies to discover modi- 
fiable AOD abuse risk factors that would respond to preventive 
interventions. For example, there is need for new prevention 
programs to test interventions which can influence the factors 
determining why some Indian youth within certain contexts 
abstain from alcohol, some become binge drinkers, and others 
become chronic heavy drinkers. 

A number of researchers have done considerable work with 
the Navajo and other American Indian tribes to try to understand 
how alcohol-related problems are moderated by a range of socio- 
economic and cultural factors (e.g., Andre, 1979; Beauvais, et al., 
1985; May, 1989; Fleming, et al, 1989). AOD abuse has been 
associated with considerable stress, feelings of powerlessness, 
and acculturation pressure and depression (Manson, et al., 1985). 
Some social scientists have suggested that, for some American 
Indians, AOD use may represent a political or symbolic resistance 
to the dominant White culture (Schinke, Gilchrist, et al., 1985; 
Schinke, Schilling, et al., 1985). For some American Indian youth, 
alcohol and other drug abuse may be related to a lack of strong 
integration into either modern or traditional society (May, 1986); 
for many youth, AOD use is congruent with perceptions of exist- 
ing peer norms (Oetting, et al., 1980, 1988). These research find- 
ings suggest that some youth do not always regard existing 
local norms of AOD use as indicating inappropriate or deviant 



154 



behavior, even though high rates of AOD use in youth and adults 
consistently alarm tribal elders. 

In sum, as with many other ethnic subgroups in the United 
States, AOD misuse and abuse are highly complex phenomena 
in American Indian communities, with AOD abuse influenced 
by a host of factors (May, 1986; Heath, 1985; Gilchrist, et al, 
1987). Many of these risk factors should be modifiable through 
culturally and developmentally appropriate preventive interven- 
tions. One could document the prevention needs of American 
Indians. However, in proposing the NAPPASA prevention 
research project to NIAAA, it was not sufficient to argue that 
the descriptive literature demonstrated great need. It was essen- 
tial also to show that there really was considerable evidence 
of strong community commitments for developing potent and 
enduring programs for AOD abuse treatment, needs assessment 
capabilities, and AOD abuse prevention. 






i . 



Overview of the NAPPASA 
Research Project 

The Native American Prevention Project against AIDS and Sub- 
stance Abuse (NAPPASA) is a multicultural, in-school, and com- 
munity outreach AIDS and alcohol and other drug abuse 
(AODA) prevention program. NAPPASA is funded by the 
NIAAA Prevention Research Branch. Its research mission is to 
collaborate with American Indian and neighboring communities 
to plan, develop, implement, evaluate, and disseminate cultur- 
ally sensitive HIV/ AIDS preventive interventions linked to AOD 
abuse prevention programs. NAPPASA's prevention goals go 
beyond improving knowledge and changing attitudes, for its 
programs are designed to: (1) change risky behaviors into health- 
protecting ones at the individual level, and (2) change community 
awareness of local health problems and risks into active partici- 
pation in prevention programs. 

All of NAPPASA's programs were expected to be (and have 
in fact been) developed through partnerships with local educa- 
tional, health, and other community-based organizations. NAP- 
PASA's staff and community partners strive to identify common 



155 






goals and values across cultures in order to further promote the 
project's guiding principle, "To Promote Health and Harmony 
by Sharing Knowledge. " NAPPASA's program materials (pre- 
vention curricula, media, training guidebooks) are also produced 
and disseminated by the partnership in ways to meet standards 
of both academic research and local customs and values. 

Research Questions. The research protocol addresses six 
broad questions: (1) Will linkage of HIV /AIDS and alcohol and 
other drug (AOD) prevention themes prove reinforcing to each 
other and strengthen motivations for prevention among residents 
of the participating American Indian communities? (2) To what 
extent can culturally sensitive ways be found to fit the local 
cultural value systems and learning styles with a public health 
oriented Social Action Theory (SAT) multimethod approach to 
prevention programming? (3) How much will the project's exper- 
imental school interventions significantly change existing HIV/ 
AIDS and AOD knowledge, attitudes, and behaviors? (4) Will the 
project's community outreach and media interventions enhance 
and sustain the school interventions and the NAPPASA research 
partnerships? (5) How much will NAPPASA's locally produced 
videos and print media increase program impact and community 
acceptance? and (6) How well will the core NAPPASA preven- 
tion intervention programs replicate across schools in Navajo, 
other American Indian, and ethnically mixed communities? 

Project Design. The NAPPASA project is designed to con- 
duct and evaluate three years of field trials of a school preventive 
intervention program based on social action theory. The school 
programs are supported by a community outreach health educa- 
tion program. Therefore, the in-school prevention curriculum 
and supporting after-school activities emphasize ways in which 
American Indian youth can build protective skills and self-effi- 
cacy beliefs. More specifically, the school-based intervention pro- 
gram is conducted as a series of quasi-experiments involving 
within and between school comparisons with annual cohorts of 
8th and 9th graders. There is a separate intervention curriculum 
for each grade. Therefore, the school prevention program is a 
two-year sequence, with the 8th grade junior high Stage 1 curricu- 
lum given first and then reinforced the following year by the 
9th grade Stage 2 curriculum. 



156 



Each of the NAPPASA prevention curricula is implemented 
with standard procedures which include: (1) standard instructor 
training, (2) culturally sensitive and developmentally relevant 
Instructor's Manuals and Student Manuals, and (3) reliable and 
locally validated baseline, post-intervention, and follow-up eval- 
uation instruments. Pairs of instructors conduct the curriculum 
in each classroom, and the qualities of their performances are 
monitored by standard process evaluation procedures. Each cur- 
riculum version (i.e., the 8th grader's Stage 1 and the 9th grader's 
Stage 2 is structured with twenty-four 50-minute scripted class 
sessions designed to build knowledge, personal skills and peer 
group norms for preventive communications and behaviors in 
the context of American Indian health beliefs and values. Addi- 
tional "booster" interventions are administered after an interval 
of several months. Informed consents for student participation 
in the prevention curricula are obtained from the community and 
school boards, from parents, and from the students themselves. 
School program assessments involve non-anonymous pretest, 
posttest, and 5-month and 12-month follow-up student question- 
naire evaluations. Both outcome and process evaluations are 
conducted. 

Outcome evaluations for the school-based interventions 
include assessing the Social Action Theory prevention model's 
antecedent and mediating processes hypothesized to influence 
future rates of AOD use, HIV/STD-risking sexual behaviors, 
and the practice of new health-promoting habits (Baldwin, et 
al, 1993). 

Process evaluations are also undertaken at key times to: (a) 
detect barriers to program implementation, (b) measure the 
fidelity of application of the standard curriculum implementa- 
tion, and (c) document the extent of student and community 
satisfaction with and cultural relevance of the preventive pro- 
grams. 2 For the current discussion about conducting research in 
racial-ethnic communities, what is especially relevant about the 
NAPPASA project is its scope (both 8th graders in junior high 
and 9th graders in senior high at-risk youth, multiple schools 
and communities), its targets (individuals and institutions), its 
prevention topics (values, sex, alcohol, drugs, etc.), and its poten- 






157 



tial for inadvertently creating a program component that would be 
incompatible with some aspects of local customs and family values. 
Therefore, it was essential for the NAPPASA project's research 
team to develop functional partnerships with members of the 
project's host communities to ensure that the new prevention 
programs would fit well with local contexts. 

Methods Used in Adapting 
NAPPASA'S Prevention 
Science to Fit with Local 
Community Contexts 

Clearly, the NAPPASA prevention project touched on a number 
of sensitive areas in its host communities as its programs were 
developed and tested. Further, some research-oriented outsiders 
were asking to make partnerships across conventional institu- 
tional and cultural boundaries to effect a complex prevention 
program at multiple levels of community life. Specifically, the 
project was asking to introduce AIDS prevention for youth as 
an urgent health concern before it was recognized as a real threat 
to local American Indian youth and adults. Further, the project 
approached both AOD abuse and HIV /AIDS as behaviorally 
transmitted epidemics. Thus, the schools were asked not only 
to consider providing class time but also to help design and 
implement a preventive education program specifically targeting 
HIV /AIDS and STD risk reduction. Given that almost no sex 
education topics or courses had been attempted before in most 
of the potential host schools, the proposed NAPPASA project 
needed considerable ' 'up-front' ' trust and political risk-taking 
by school boards and administrators. 

One more issue complicated the project's entry into commu- 
nity life. The project began partnership negotiations during the 
time when major campaigning for reservation-wide elections 
was under way. Therefore, when the project team arrived in 
northern Arizona, each community was engaged in choosing 
candidates to support for tribal chairman, tribal council represen- 
tatives, local chapter representatives, and — perhaps especially — 



158 






for local school boards. In sum, this was a time of important 
changes in the social and political climates of the host communi- 
ties. Fortunately, initial concerns that the federally funded NAP- 
PASA prevention project could become a political issue proved 
to be unfounded. NAPPASA did not get politicized even though 
it was asking for some courageous decision-making about a very 
difficult kind of health promotion and disease prevention pro- 
gram. 

NAPPASA's discovery of a potentially sensitive mixture of 
prevention topics, targets, politicized groups, and local commu- 
nity history is not an uncommon situation for prevention 
researchers desiring to come to racial-ethnic communities in 
order to form new research partnerships. Whenever possible, 
ample time should be provided in the project's time frame to 
discover harmonious ways to work together toward common 
prevention goals. With the NAPPASA project, a specific mixture 
of activities was undertaken to cope with the challenging issues 
and potential barriers encountered in working with its host reser- 
vation and border town communities. In fact, these activities 
defined much of the scope of work during the project's first year. 
During this first and subsequent years, the research team came to 
perceive several underlying themes and issues (described below) 
which had to be addressed regularly to ensure that the 
researcher-community partnerships remained functional and 
truly collaborative. 

Themes in Making NAPPASA's 
Prevention Partnerships Functional 

Effecting Local Leadership 

The most important initial tasks for the academic research team 
were to recruit and hire two local project leaders to serve as 
the On-Site Project Director and the Coordinator of Community 
Programs. The On-Site Project Director 3 was chosen for her pre- 
vention research expertise. Given that she had American Indian 
ancestry but was not a member of one of the local tribes, it was 
very important that the NAPPASA project find a local Navajo 



159 



person for the position of Coordinator of Community Programs, 
as the research team was working in predominantly Navajo 
communities or those bordering the Navajo Reservation. The 
project was fortunate to recruit for the Community Program 
Coordinator a culturally traditional woman 4 , fluent in both Nav- 
ajo and English, who was well known to the local education and 
health services networks. She has filled an essential role by being 
the local project leader who remained most focused on keeping 
the program both relevant and sensitive to traditional cultural 
and community concerns even if her Anglo-American academic 
research colleagues failed to understand important subtleties in 
these areas. 

As will be discussed below, the issue of "Being There" to 
work on the reservation and being from the reservation commu- 
nities was a critically important issue in building the long-term 
prevention partnerships with local people. The project would 
have taken a serious misstep had it not chosen a local Navajo 
person as its community program coordinator, or had its On- 
Site Project Director not chosen to live part time in one of the 
reservation communities. 

Building From Local Initiative by Telling 
the Origin Story 

This was a very important task for the project leadership during 
its first year. As is the case for the gatekeepers in any community 
who are being asked to form a research partnership with outsid- 
ers, the NAPPASA project's Navajo community gatekeepers 
wanted to understand several things up front: 

• What did the project's researchers propose to do? 

• Why should they do it in or near the reservation communi- 
ties? 

The project's origin story answered these two key questions. 
In brief, the NAPPASA project's origin story told how the princi- 
pal investigator (J. Rolf) was invited to come to Arizona. The 
invitation arose when a local Navajo community (Leupp) school 
board came to Johns Hopkins University to inquire about the 
HIV /AIDS epidemic's potential threats to Navajo adults and 



160 



youth. After meeting with the author (Jon Rolf), the board 
decided that the AIDS threat could become a real one to their 
own community and that this threat might grow larger with 
time. Therefore, the school board asked the author if he would 
come out to Arizona and help them plan an AIDS prevention 
program for their school. When he responded that he only knew 
something about HIV /AIDS prevention but not about Navajo 
people, the Navajo members of the school board laughed and 
said, "You help with the AIDS part and we'll take care of the 
Navajo part." 

Telling how local initiative was involved in the NAPPASA 
origin story was an essential step in establishing the project's 
legitimacy: namely, the public health researchers were invited by a 
local school to come and work with them. Another question answered 
by the origin story concerned the NAPPASA project's funding. 
Because there was no local funding for such a program, the 
author was encouraged by the local communities and schools to 
seek funds through writing prevention research grant proposals. 
When the research funding was obtained, the author returned 
to Arizona to tell how the NIAAA Prevention Research Branch 
saw the merits of funding a joint AOD abuse and HIV /AIDS 
project conducted by Johns Hopkins faculty in partnership with 
educators and health service providers from American Indian 
communities in northern Arizona. Because the project's origin 
story involved local initiatives and had brought new external 
funding, the community people were ready to ask the next ques- 
tions: "Why us? And why you?" 

Justifying the Cross-Cultural Partnership 
by Answering Why Us? And Why You? 

These questions are always asked of prevention researchers who 
come from outside a racial-ethnic community to start a new 
program. For the Navajo communities' gatekeepers, these ques- 
tions may have been particularly important for several reasons 
related to their tribe's historic relationships with White men 
and women. Several probes were often added to their basic 
question — "Why You?" These were: 



161 






• Why are you, another Anglo from around Washington, 
D.C., coming to our reservation expecting us to want to 
be a part of your health program? 

• Why should we want to help another Anglo researcher, 
because some 

• of you researcher people have previously only taken from 
us and never given us things of lasting usefulness?'' 

There are a number of levels of communication in these 
questions. Some of them are a normal part of negotiating con- 
tracts and partnerships. In addition, there was a special emotion- 
ally charged concern that needed to be laid to rest before the 
NAPPASA project could begin. This concerned "Why Us — Why 
the Navajo?" The academic public health research team told the 
community they had come only because they had been asked 
by some local people. Finally, the academics acknowledged that 
they had been made aware of the local prevalence of AOD abuse 
and interest of community leaders in creating new prevention 
programs through partnerships. However, it was also very 
important to explain that the research team had not come to 
Arizona's American Indian communities because the researchers 
thought them to be "worse" or more in need than where they 
themselves had come from. Instead, it would be "up to us, 
together," to prove that the new prevention programs created in 
partnership could make a difference in the rates of future prob- 
lems right here in Navajo land. These explanations seemed to 
help clear some tensions about "Why Us — The Navajo?" 

With regard to "Why You — the Johns Hopkins Researchers?" 
the community people seemed to respect the fact that the preven- 
tion researchers had previous experience developing prevention 
programs for their own home communities and for other racia- 
l-ethnic communities that had invited their help. It was impor- 
tant that the researchers were willing to do the kind of work 
in Arizona that was valued in their home communities and 
elsewhere. What the Johns Hopkins team did not fully realize 
then was that their explanations may not have addressed some 
local individuals' expectations that the unspoken research goal 
was to study the worn-out stereotype of "drunken Indians." 
Therefore, in some meetings, it was important for the research 



162 



team to specifically distance itself from this particularly noxious 
stereotyping. 

The NAPPASA prevention researchers were also prepared 
to negotiate and somehow demonstrate the understanding that 
all parties could and must find highly visible ways to share 
power, resources, and values to start the prevention partnership 
and to avoid an ongoing "US vs YOU" power struggle. To be 
an effective leader in the NAPPASA project required the ability 
to cope with many seemingly conflicting cultural, political, fiscal, 
managerial and scientific issues. What was unique for the author 
in negotiating partnerships with local Navajo communities was 
the experiencing of a different kind of racial tension (i.e., Indian 
vs. Anglo) combined with a prevalent, pre-existing attitude invol- 
ving willingness among some local community persons to 
express overt rejection of all research projects in general (i.e., 
"All research is bad for the community"). 

Part of this difference in perceived cross-cultural tensions 
may be due to several facts. First, the reservation communities 
are located on separate sovereign nation states within the United 
States. Second, these sovereign Indian Nations are frequently in 
court fighting against various programs controlled by the State 
or Federal governments or private non-Indian corporations. The 
Johns Hopkins scientists had to come to understand these facts. 
Looking back, the author now believes that he was handicapped 
in partnership negotiations because he had grown up in environ- 
ments where he had seen no Indian- Anglo hostilities. The author 
did not know how to confront these historic hostilities and the 
undercurrents of racial prejudices. The author missed some sig- 
nals when local people expected him either to reveal or to dis- 
avow the expected enemy Anglo role. 

For example, as Anglo-Americans wanting to work in Indian 
country, the author and the other academic researchers had to 
learn and to accept that some potential partners (and some Amer- 
ican Indian project staff) would expect them to be truly preju- 
diced against American Indians. They expected that this preju- 
dice would be expressed both overtly and subtly in the project's 
research goals, in project staff hiring, in sharing control of the 
project's agenda, and especially in the taking of data from the 



163 



participants. The principal investigator especially had to learn 
to confront stereotypic expectations that he would prove to be 
secretly, deep down, prejudiced against Indians; that he might 
be, deep down, not really committed to serving the prevention 
needs of local communities; or that he would be covertly trying 
to "take more than he would give/' 

For the author, there were two distinct phases to confronting 
community expectations of anti-Indian prejudice. The first stage 
was to show that he would not take it personally; that is, to 
accept the legitimacy of the historic distrust of Anglos while 
explaining why he would be an exception to the rule. The second 
stage was harder for him to accept, for he had to discover and 
to define his personal limits to being stereotyped as anti-Indian 
simply because he is Anglo. Discovering these limits, he had to 
start taking very personally local persons 7 attributions that he 
was expected to be anti-Indian. This stage was reached probably 
because there were some NAPPASA partners who very much 
wanted the project to work and who hoped to be extremely 
committed to its goals. For them, the project was potentially very 
important to their people, and therefore they most feared the 
project's potential for doing their people real harm if the project's 
leaders had false faces. In their logic, were they to support this 
powerfully important project and the principal investigator's 
leadership as an outside researcher, they too might become ene- 
mies of their people if the project had false goals. 

For the author and other non- American Indian researchers 
on the NAPPASA project, "taking it personally" meant being 
ready to tell how one's personal values, long-standing commit- 
ments to public health, and dedication to seeing the collaborative 
project through deserved more than stereotypic suspicions and 
hostility. The bottom line was this: "There has been bad history, 
but there can be a new positive history in prevention working 
with this team of Johns Hopkins public health scientists. Believe 
it, work with it, or leave the project partnership." In retrospect, 
the NAPPASA project experience taught important lessons to 
its outsider researchers about how everyone must expect to check 
their real values and motives and to emphatically declare them 
in order to become true partners with community partners. Such 



164 



declarations may be most necessary to give to those who may 
have the most to offer the project in return. 

Effecting a Long-Term Prevention 
Agenda by Giving More Than Getting 

' 'Researchers always take too much and give too little' ' was 
another common concern voiced in NAPPASA's host communi- 
ties, and this concern has been voiced in other prevention projects 
(e.g., Fawcett, 1991). In negotiating the NAPPASA project part- 
nerships, the research team repeatedly heard from different com- 
munity groups how no one was interested in "one-shot" pro- 
grams. When it was explained that the NAPPASA project was 
designed to provide four years of new school and community 
programs, the rejoinder often was: "But four years is not very 
long." In response to this issue about the project's intentions to 
make long-term investments in the community, several addi- 
tional commitments were emphasized by the project's research- 
ers. These were: 

• the project is investing in a wide range of community 
consultants and staff to ensure that our prevention pro- 
gram products fit into and can be sustained by the commu- 
nity's institutions and value system; 

• The project is training the local schools' regular teachers 
and co-instructors (recruited from the community) to 
implement the program; they would still be in the commu- 
nities to use their new knowledge and skills even after the 
outsiders leave; and 

• The researchers on the project are helping write new grants 
to continue the prevention programs if the program evalu- 
ations proved them to be effective. The project has followed 
through on each of these commitments to long-term invest- 
ments. 

With regard to the issue of not taking more than they give, 
the outsider researchers on the NAPPASA project's research 
team sometimes had to prove that they were not working in 
Arizona simply to further their careers. This issue arose when 
community gatekeepers voiced suspicions that the researchers' 



> 



165 



f 






motivations for doing the program were primarily to: (1) advance 
themselves via gathering data for publications which would lead 
to fame and promotion, (2) use grant staffing funds for external 
instead of community people, or (3) pursue some kind of tourist 
or missionary purposes (it's fun to come to exotic places and to 
work with different people). In their work on the project in 
northern Arizona among American Indian communities, the 
NAPPASA prevention researchers came to expect that they 
would need to justify and rejustify themselves on these issues 
in both public and small group meetings. 

One of the methods that the academic researchers used to 
ensure that a long-term agenda was developed and followed 
was the institutionalization of an active NAPPASA Advisory 
Board whose members were nearly all American Indians and 
local residents. These advisors were very helpful in focusing 
the project agenda on making long-term investments, on the 
importance of local values, and on the necessity of obtaining 
local input at each successive stage of the project. The advisors 
were also able to require that the principal investigator rejustify 
his motivations and goals during Advisory Board meetings so 
that these questions and his answers could be safely observed 
by the project's American Indian staff. 

Obtaining Local Input by Listening to 
What They Have to Say 

Being a good listener is valued by many cultures and by 
most persons in functional partnership endeavors. However, it 
is rarely clear how being a good listener will be defined by 
different speakers, especially when there are cultural differences 
between the speaker and the listener. Sometimes, it is simply 
the very act of listening that is the main point. Proving that you 
have been, are now, and will be listening may be the message that 
community gatekeepers want to get from the prevention researchers. 
This was true on the NAPPASA project even when it became 
apparent after a good amount of listening that there was great 
commonality in personal values and commitment to the preven- 
tion program between the outsider research team and their com- 



166 



munity partners. As has been discussed in the "Why us, Why 
you?" issues, the act of listening to how American Indian values 
could shape the programs served to validate the legitimacy of the 
community's active role in shaping the prevention partnership. 

Some of the NAPPASA project's more effective demonstra- 
tions of "listening to what they have to say" arose from two 
qualitative methods of formative research: (1) focus groups, and 
(2) key informant interviews with different subgroups within the 
host communities. Focus groups had been planned as an impor- 
tant part of NAPPASA's pilot year research protocol in order to 
elicit three kinds of information: (1) any existing styles of dis- 
course about HIV/ AID and AOD, (2) channels of communication 
on HIV /AIDS, AOD abuse, and (3) local preferences for includ- 
ing these topics in prototype school- and community-based pre- 
ventive intervention programs. 5 In all, the project successfully 
conducted 14 focus groups early in the first year. The group size 
was small (six to eight persons), they were separated by gender 
for the youth groups, and they were conducted by carefully 
trained, context- appropriate group facilitators. A short list of 
questions was asked in a non- threatening sequence. The focus 
groups provided very useful information about: (1) baseline 
knowledge and communications and possibilities for interven- 
tion prototypes (Trotter, et al., 1993a) and (2) health beliefs 
including risks for HIV/ AIDS and AOD abuse and their pre vent- 
ability through risk avoidant behaviors (Trotter, et al., 1993b; 
Quintero, et al., 1992). The lesson about the use of focus groups 
in the NAPPASA project seems clear: focus groups are an effec- 
tive and efficient qualitative research method to use with Ameri- 
can Indian youth, especially for exploring culturally sensitive 
topics. 

Listening through focus groups helped to sustain NAPPA- 
SA's prevention partnerships in several ways beyond providing 
the data needed to create culturally sensitive prevention pro- 
grams. One unanticipated, yet serendipitous, payoff from NAP- 
PASA's use of the focus group method was that the focus groups 
themselves came to be perceived by the community as important, 
tangible demonstrations of the project's commitment to truly 
listening to the local people. Focus groups helped prove that the 



167 







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outsider academic researchers really wanted to understand local 
customs and values before intervening to change anything. 
Taken together with the obvious other activities (e.g., interviews 
and dialogues with community gatekeepers, staff presentations 
in English and in Navajo at local community chapter and school 
meetings), people began to view the research team as "good 
listeners" and as people who could be trusted to seek local input, 
to value it, and to keep seeking more of it. 

The project leadership is now aware of the importance of 
the process of listening to the community and the useful roles 
that ethnographic methods of formative research play in this 
process. Consequently, focus groups in the NAPPASA project 
have evolved from an experimental formative research tool to 
a regularly used method for maintaining ongoing community 
dialogues and for conducting process evaluations with preven- 
tion program participants. Post-intervention focus groups have 
been conducted regularly with teachers and students (separately) 
to understand and to correct unsatisfactory intervention assess- 
ment questionnaire items and intervention curriculum compo- 
nents. Most of these groups are audio-recorded and catalogued 
and quantified for feedback to the research and community mem- 
bers of NAPPASA's project team. 

The project has also begun to videotape focus groups and 
gatekeeper interviews and to show appropriate excerpts at com- 
munity meetings. The project staff have been very surprised to 
discover how focus group videos containing visually recorded 
statements of personal participation in and contributions to the 
NAPPASA prevention program are culturally congruent and 
powerful means to sustain the research partnerships. Audiences 
of all kinds attend carefully to these videos and seem to find 
personal connections to these speakers and their messages. The 
research team also became aware of the importance of sharing 
what is heard by producing a variety of other kinds of videos 
well beyond the small number envisioned and described in the 
original grant proposal. The description of how NAPPASA's 
video media became an important intervention approach follows 
a discussion of the next partnership building activity, "Being 
There." 



168 






Showing Respect and Building Mutual 
Trust by Being There 

This theme in NAPPASA's partnership building process has 
involved a number of overt and covert tests of the research 
team's adaptability to ways in which local people build working 
relationships with outsiders. The easiest test of "Being There" 
involves demonstrating one's willingness to participate in com- 
munity social and cultural events that are not directly related to 
the project's research agenda (e.g., sporting events, political ral- 
lies, pow-wow's, and — with special invitations — traditional cer- 
emonies). For some traditional Navajo people, the way an out- 
sider shows respectful interest (but not invasive participation) 
at cultural events is an important sign of his/her adaptability 
to how things are and should be done locally. Not infrequently, 
"being there" also means showing a willingness to extend one- 
self. This may mean taking things slow. This can be a challenge 
to outsider researchers who come from time and status con- 
scious cultures. 

Being confronted with inconveniently delayed schedules and 
undehnable time frames are very real tests of prevention 
researchers who want to work in some American Indian commu- 
nities. These tests can take a number of forms, but the ones 
encountered most frequently with NAPPASA involved: (1) wait- 
ing several hours for scheduled and confirmed appointments at 
meeting places chosen by gatekeepers, (2) failing to attend a 
scheduled event or coming unannounced at a later date to a 
previously missed meeting, or (3) being bumped from a pub- 
lished meeting agenda even when a special trip of hours or days 
has been made to be present for the agenda item. Whether or 
not these inconvenient problems in "Being There" were uninten- 
tional occurrences or planned tests, they provided useful oppor- 
tunities to prove something about the NAPPASA project team. 
Perhaps the most important point to prove on these occasions 
of inconvenience and lost time was to underscore the project 
research team's continuing commitment to its community part- 
ners — that the project research team is still there, that it will be 
there in the future, and that the community can trust the team 
members to do what they say they are going to do. 



169 



Strengthening NAPPASA's Partnerships 
Through Video Media 

In writing the grant proposal, the principal investigator asked 
the reviewers to consider the one or two planned media produc- 
tions as potentially useful supportive activities for the school- 
based intervention program. The theoretical bases for choosing 
the messages and communicators in the videos would be congru- 
ent with key elements of Social Learning Theory (Bandura, 1986) 
and the Diffusion of Innovations Communications Model (Rog- 
ers, 1983). Again, focus groups and other ethnographic interview 
methods were proposed during piloting approaches to identify 
existing local health beliefs and communications about HIV/ 
AIDS and AOD abuse. This formative research was expected to 
provide information on culturally sensitive and initially useful 
prevention messages and spokespersons. In sum, the project 
£j would produce media to achieve two research objectives: (1) 

media targeting the community would prime adult audiences 
(parents, gatekeepers, and elders) to want to support and partici- 
pate in AIDS /AOD prevention programs and (2) school preven- 
tion curriculum media modules would show local peers model- 
ing and being reinforced for practicing preventive communica- 
tions skills and choosing attractive low-risk behavioral options. 
Working toward both of these objectives had greater than antici- 
pated payoff for NAPPASA. 

Before beginning any video production, the research team 
already knew that these media would: (1) demonstrate how the 
prevention programs would address the values, health beliefs 
and cultural sensitivities of the participants and (2) connect them 
to local epidemiology of the HIV /AIDS and the AOD abuse 
epidemics. The team did not expect that NAPPASA's media 
instead: (1) would serve as the community's window on the 
research team's own values, health beliefs and cultural sensitivi- 
ties and (2) would empower more local persons to become per- 
sonally involved as spokespersons for prevention. 

In retrospect, the project's first video production objective 
was a fortuitous big step toward extending the community pre- 
vention partnerships. The principal investigator had simply wan- 



170 






ted a replicable, highly visual introduction to the project which 
would tell the project's origin story, explain its methods, and 
show the project's research team and its initial community part- 
ners speaking in their own words about the need for a local 
prevention project and their own roles in it. An interesting proto- 
type video was produced by the project's videographer-anthro- 
pologist, but the project's American Indian Community Advisory 
Board found it unacceptable. Their judgement was, "Too many 
Anglo (White) faces!. . . .Not enough local people." This defi- 
ciency was corrected by adding many new visuals, voices, and 
sounds drawn from local contexts. For example, one new seg- 
ment showed a very persuasive local Navajo man in recovery 
from substance abuse describing what he felt like when he 
learned about his many personal risks for HIV. He expressed 
fear that he may have infected his family with the AIDS virus. 
Other new segments showed NAPPASA's focus groups, its cur- 
riculum instructors being trained and implementing the pilot 
curriculum in local classrooms, the project's Navajo community 
outreach coordinator at a chapter meeting, and community resi- 
dents being surveyed for their opinions about what was needed 
for the community prevention program. Finally, a new title — 
"It's Up to You" — was added to complete the revision of the 
NAPPASA project introduction video. The re-edited video was 
then judged by the Advisory Board to be much more relevant 
to the host communities, because it showed that the project 
belonged to the local people and was being shaped by them. 

During the second grant year, "It's Up to You" opened many 
doors for the project. Nine schools and their many surrounding 
communities on and bordering the western Navajo Nation and 
the Hopi Nation joined the project. The video also had powerful 
messages for Puyallup people in Tacoma, Washington (who 
brought NAPPASA's programs to their schools), and other audi- 
ences across the United States. The success of "It's Up to You" 
encouraged NAPPASA to find resources in order to make many 
more kinds of project videos. They, too, have proven to be very 
important in making NAPPASA prevention research programs 
locally relevant and effective. 6 



171 



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Delivering Prevention Program Products 
to the Community 

The NAPPASA project has been committed to giving as much as 
possible to its community partners. In addition to the prevention 
programs delivered in the schools and communities, and in addi- 
tion to the project's prevention network building services in the 
community, NAPPASA's research team has produced a substan- 
tial number of useful products which should endure beyond the 
life of the research project. These include the over two dozen 
videos which are distributed locally by NAPPASA and nationally 
by the Indian Health Service AIDS Program. The DHHS Center 
for Substance Abuse Prevention has also supported the prepara- 
tion and national distribution of two NAPPASA videos ("It's 
Still Up To You" and "Sharing The Prevention Vision") and the 
NAPPASA prevention program school curricula (NAPPASA, 
1993). These 8th grade and 9th grade preventive intervention 
curriculum packages will be available at no cost to other Ameri- 
can Indian communities by early 1994. The curriculum packages 
contain Instructor's Manuals, Student Manuals, After-School 
Activities Guides, and Instructor's Training Guides (NAPPASA, 
1993). There are also two versions of student-created NAPPASA 
photo-novels to serve as booster interventions. NAPPASA has 
also produced culturally relevant AIDS and AOD abuse preven- 
tion posters and flyers. Together, the project's products, staff 
and community partners are producing what appear to be well- 
liked preventive intervention materials. NAPPASA's interven- 
tion programs have produced interesting findings on their effec- 
tiveness in modifying behavioral risks for HIV /AIDS and sub- 
stance abuse. 

Research Findings 

NAPPASA is funded as a research project and not as a demon- 
stration of a prevention service. The research team is very aware 
that knowing how to build prevention partnerships and telling 
how the prevention research was accomplished are more inter- 
esting if the research interventions produce meaningful changes 
in persons at risk. In the second project year (April 1991 to 



172 



March 1992), NAPPASA began the full implementation of the 
intervention field trials in American Indian schools and commu- 
nities on and off the local reservations. The project was able to 
meet or exceed its objectives in the areas of: (1) the participation 
of students, schools, and communities, (2) the development of 
culturally sensitive prevention curricula and evaluation mea- 
sures, (3) the production of supporting media for use in the 
curricula and community outreach programs, (4) the numbers 
of American Indian and mixed communities actively supporting 
or requesting prevention research partnerships with our project, 
and (5) the dissemination of prevention program materials and 
research findings. Accomplishments in several of these program 
areas for the project's second year — the first field trial year — 
are summarized briefly below. Additional results are reported 
elsewhere (Baldwin, et al., 1993; Rolf, et al., 1993). K 

School Partnerships. After the pilot year findings were 
available, the research team proposed increasing the number of 
schools receiving intervention from the three planned schools 
to insure obtaining adequate numbers of subjects within grades 
and to decrease potential subject attrition due to school transfers. 
In fact, active partnerships were achieved with nine schools in 
Arizona in the second year (not counting the two Chief Leshi 
schools in Tacoma, Washington). Three of the nine Arizona 
school partners are high schools and six are junior high schools. 
Excluding the Flagstaff school system, the collaborating schools 
represent the major schools serving youth from the southwestern 
Navajo Reservation and the Hopi Reservation. 

Subject Recruitment and Retention. During the second 
and third project years, over 2,000 adolescents from rural Reser- 
vation and border town communities participated in the NAP- 
PASA prevention curricula. In taking the program, they have 
provided high-quality, longitudinal, non-anonymous data about 
their thoughts, behaviors, and intentions on a broad range of 
prevention topics. During the 1991-92 school year, 872 eighth 
and ninth graders participated in intervention or non-interven- 
tion conditions. About half were eighth graders and half ninth 
graders. Recruitment and retention were excellent, with 95% of 
the total grade samples participating at baseline and one month 



173 



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posttest and 88% reassessed at three to six month follow-up 
assessments. (During the 1991-92 field trial, intervention was 
also provided to 100 urban junior and senior high school students 
at a BIA school in Tacoma, Washington, where the NAPPASA 
program was invited in to help cope with the urgent prevention 
programming needs which arose with the discovery of an HIV- 
infected high school student.) 

Outcome Findings. Only the initial findings from pretest 
to posttest comparisons are presented here, and they are very 
encouraging. Longer term results are reported elsewhere (Rolf, 
1992; Rolf, et al., 1992; Baldwin, et al, 1992; Rolf, et al., 1993). 
Analyses on a sample of 460 ninth graders (86% American Indian, 
55% female, mean age = 14.6) from two reservation high schools 
and one border town high school indicate that the five-week 
NAPPASA Stage 1 school-based interventions produced positive 
changes in targeted AIDS and AOD abuse prevention areas. 
Process Evaluations revealed NAPPASA's school-based curricu- 
lum also produced high approval ratings from the participants, 
the students, the teachers /instructors, and the schools 7 adminis- 
trations. The self-report questionnaires used at baseline and at 
the post-intervention five weeks later (95% retested) indicated 
statistically significant positive changes (p<.01, 2-tailed) from 
pre-test to post-intervention. In sum, the outcome evaluations 
revealed that the NAPPASA intervention curricula increased: 

• AIDS and AOD abuse knowledge 

• self-efficacy for specific prevention skills 

• ease of communication about STDs, AIDS, sex, AOD abuse 

• perceptions of harm from drinking 

• belief in alcohol's increasing one's risks for AIDS 

• belief in ability to help protect friends and family from 
AIDS 

• personal concern about AIDS threats 

• belief in the importance of values (personal, family, and 
cultural) in helping one avoid risky behavior. 

In addition, the outcome evaluations also revealed that the 
NAPPASA intervention curricula decreased: 

• misconceptions about vulnerability to HIV infection 

• reported availability of AOD when teens got together 
socially 



174 



• self-image as someone with a heavier drinking style 

• cigarette use 

• thinking about the good and bad outcomes of sex 

• belief that it is improper to talk about sex, STDs, and AIDS. 

Other analyses (reported elsewhere) show that the post-inter- 
vention gains were sustained for three to six months, as indicated 
by follow-up evaluations. Additional analyses also examined 
subgroup differences in outcomes as a function of baseline levels 
of drinking, sexual activity, and beliefs. 

Concluding Comments 

There is always so much more to learn from working in preven- 
tion research partnerships with communities, and especially 
when the partnerships cross cultural boundaries between the 
community groups and the research teams. Both groups can 
quickly find some common ground when they communicate 
their feelings and values concerning the new prevention services 
to be provided in the research program. Each group can gain 
further respect from the other when they find ways to actually 
demonstrate how specific services can be created locally to help 
improve the quality of life and the health of the community. The 
community partners themselves need to recognize that they can 
gain the trust of the researchers by explaining clearly how inclu- 
sion of local customs can increase the acceptance and the effec- 
tiveness of the new prevention program. The prevention 
researchers also have an obligation to foster cross-cultural under- 
standing by describing to their community partners the culture 
and values that are part of academic, theory-based research. It 
should be made very clear to the community that there is little 
credit from academia for donating the researchers 7 time to build- 
ing community prevention research partnerships, working to 
promote an at-risk community's empowerment in prevention 
programming, or for developing functional, culturally sensitive 
prevention programs unless these activities lead to scientifically 
sound, publishable data. When such cross-cultural communica- 
tion is achieved, the prevention partnership will produce useful 
products and growth , experiences for both the research team and 



175 



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community participants. On the community side, the experience 
of creating and evaluating the new prevention programs should 
give them a sense of empowerment and accomplishment. On 
the other side, if the partnership creates a prevention program 
that produces scientifically sound evaluation data, it gives the 
prevention researchers a gift of an improved quality of life in 
academia. The NAPPASA project is giving such gifts to its 
partners. 

References 

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Behaviors, 6:75-81, 1981. 

Baldwin, J., Rolf, J., and NAPPASA Staff. Promising HIV/AID prevention 
outcomes for Native American youth. American Public Health Association 
meeting, Washington, D.C., October, 1992. 

Baldwin, J., Rolf, J., Johnson, J., Alexander, C, and Benally, C. Methods and 
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. 












• i 







Quintero, G., and NAPPASA Staff. The Use of Focus Group Interviews in 
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End Notes 

1. The author's prevention research experience spans twenty 
years during which he has served in various research roles 
ranging from an academic institution-based principal investi- 
gator and co-investigator on research grants to a visiting scien- 
tist staff person in National Institute of Mental Health's Pre- 
vention Research Program. The author has helped design and 
implement field preventive intervention projects in the 
nascent day care system of Vermont during the 1970s in 
schools in rural Harford County, Maryland, in inner-city Balti- 
more neighborhoods, on the streets and favelas of Belo Hori- 
zonte, Brazil, during the 1980s and during the early 1990s in 
some American Indian communities and schools in northern 



■ 



Arizona and Tacoma, Washington. Each of these different 






settings required hard work toward achieving some common 
prevention research objectives: (1) gaining admission to the 
community, building trust, (2) performing the promised pre- 
vention intervention in scientifically and culturally acceptable 
ways, and (3) disseminating scientific reports and locally 
usable prevention program products. In the author's experi- 
ence, there have been some commonalities in how these 
research objectives have been reached across these community 
settings. However, there have also been considerable differ- 
ences in the type of approaches and the extent of the research 
projects' resources devoted to achieving these research objec- 
tives. This variation results from differences in each host com- 
munity's local history with outsiders, culture, institutional 
structures, and favored socio-political processes for develop- 
ing prevention programs for behavioral health problems. 
More detailed information on the NAPPASA project's pro- 
gram development activities, its preventive intervention pro- 
gram products, and the findings of the held trials can be 



179 






obtained from the author. Manuscripts are from Baldwin, J., 
et al., 1993; Rolf, J., 1992; Rolf, J., et al, 1993. 

3. The position of On-Site Project Director is capably filled by 
Dr. Julie Baldwin, who shifted her permanent home from 
Baltimore to Flagstaff, Arizona, at the start of the project. She 
holds a Ph.D. in Behavioral Sciences from the Johns Hopkins 
School of Public Health, and she has great expertise in the 
development and evaluation of school-based prevention pro- 
grams. 

4. The Coordinator of Community Programs for the NAPPASA 
Project is Rose Denetsosie. She has served the project and the 
local people extremely well by building effective channels of 
communication between the project and the community so 
that all could share their prevention visions with creativity, 
integrity, and courage. 

5. Actually running the focus groups was vital to creating the 
needed support from the community. They helped overcome 
some existing cultural stereotypes and program barriers that 
are typically found in the formative stages of research into 
AIDS prevention. Sometimes the barriers to be overcome are 
also found in the scientific community. With the NAPPASA 
project, it turned out that simply proposing to conduct focus 
groups, in the absence of published reports on American 
Indian focus groups, almost jeopardized the funding of the 
project. An anthropologist scientific peer reviewer of the NAP- 
PASA grant proposal had predicted that the proposed focus 
group discussions about sex and sexual transmission of HIV/ 
AIDS probably would not work with Navajos because the 
topics were culturally too sensitive and perhaps even 
' Taboo. " Further, this peer reviewer reasoned that if there 
were real cultural barriers to focus group discussions, then 
there might be fatal scientific flaws in the grant proposal's 
theory-based preventive intervention (i.e., focus groups 
would be the wrong qualitative research method, and the 
proposed peer group-based skill-building interventions to 
strengthen preventive communications and risk reduction 
attitudes about unsafe sexual behaviors probably would not 
work either). Fortunately, the majority of the NIAAA Initial 



180 



Review Group (IRG) committee saw the plans to use group- 
based formative research techniques and social cognitive the- 
orv-based interventions as a common-sense, best-bet 
approach to discovering and developing an effective cultur- 
ally relevant prevention program. The research team's success 
with focus groups also led to an invitation to conduct some 
groups with American Indian vouth m Los Angeles for a 
DHH5 study on HIV prevention for hard-to-reach youth ( Kar- 
imi, et al, 1991). 
6. There are now several tvpes of videos: ( 1 ) Introduction to XAP- 
PASA — introduces new schools to the project's purpose, 
methods and staff, as well as to the project's commitment to 
a spirit of continual sharing between the givers and the receiv- 
ers of the project's programs; (2) Prevention for Tico Epidemics 
— introduces local communities to the linkage between the 
HIV/AIDS and AOD abuse epidemics; (3) Local Spokespersons 
& Role Models — shows local spokespersons and role models 
delivering educational motivational messages about preven- 
tion in their own words to the communitv m recognizable 
settings; (4) Curriculum Segments — integrates into half of the 48 
XAPPASA intervention curriculum class sessions information 
on identifying targeted problems, suggesting positive options, 
and modeling preventive behavior by peers. 



181 



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Part IV 



Alcohol Prevention 
Research in Ethnic/Racial 

Communities: 
Case Studies 

Introduction 

Part IV of this monograph examines the four major ethnic /racial 
communities included in the working group: American Indians 
and Alaska Natives, Hispanics, African Americans and Black 
Americans, and Asian Americans and Pacific Islanders. 

Each section of Part IV corresponds to the four major ethnic/ 
racial communities. Each section contains three papers. First, a 
paper is written by an academically based researcher and focuses 
on current research findings and state-of-the-art research. Sec- 
ond, a paper is written by a community-based researcher and 
focuses on specific community studies. Finally, the third paper 
in each section is a discussion paper and is written by a community 
advocate, clinician, or representative from each ethnic /racial 
group. The papers show diversity in focus, format, and depth 
of presentation. With one exception (May), all papers in Part IV 
are written by members of the corresponding ethnic group. 

The diversity in focus reflects one major objective of the 
working group: to foster a dialogue among the various groups 
of professional researchers, community strategists, advocates, 
clinicians, and representatives who are working to prevent alco- 
hol-related problems in ethnic /racial communities. Collabora- 
tion can be developed and new alliances built between academic 
researchers and ethnic/racial communities from this dialogue. 



183 



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Affirmation of this need for dialogue arose as the working 
group was organized and speakers were selected for each ethnic/ 
racial group. On the one hand, some community members 
argued that research findings that emanate from the academy 
are not useful to the community where people live and die of 
alcohol-related problems. This is so, they continue, because the 
scientific findings in no way reflect what is actually happening 
in the community. On the other hand, some academic researchers 
argue that they do not have access to ethnic communities to 
conduct scientific community studies. Some community repre- 
sentatives stated that academic researchers raid and pillage com- 
munities to obtain what academic researchers need to further 
their research careers. Finally, some community members were 
concerned because academic researchers have not approached 
their communities for purposes of doing research. 

The structure of the working group provided all groups the 
opportunity to identify the most effective ways to conduct pre- 
vention research to benefit both the ethnic /racial groups and 
research communities. The hope was that a dialogue between 
academic researchers and ethnic /racial communities would 
increase future collaboration between them, develop greater sen- 
sitivity among researchers to the specific prevention needs of 
ethnic communities, and develop relationships of trust between 
researchers and community members so that relevant research 
could be designed and useful prevention strategies could be 
implemented. 

Academic researchers and community members need to 
understand and analyze the social processes that take place in 
their interaction. It is in this interaction where the hazards lie. 
The prevention of alcohol-related problems can be found in this 
interaction. The working group discussions and the papers in 
this section reflect the efforts of all groups to improve the quality 
of alcohol prevention research in ethnic /racial communities. 
Quality research is needed for quality service provision in these 
communities. 



184 



9 

The Prevention of Alcohol 

and Other Drug Abuse 

Among American Indians: 

A Review and Analysis of 

the Literature 

Philip A. May 



Introduction 

The 1990 Census counted 1,959,873 American Indians and Alaska 
Natives in the United States, which is 0.8% of the entire popula- 
tion (U.S. Bureau of Census, 1991). There are currently over 300 
federally recognized tribes, and the social and cultural variation 
among them is great. Although an increasing proportion of Indi- 
ans and Alaska Natives are now living and working off-reserva- 
tion, Indian populations tend to cluster in the Western states 
both on and next to reservations, and in municipalities that are 
near reservations. Sixty-six percent of all Indians live in ten states, 
eight of which are in the West or Midwest (Hodgkinson, Outtz, 
and Obarakpor, 1990; Snipp, 1989). 



Clerical support was provided by ADAMHA Grant T34-MH19101. Special thanks 
to Phyllis Trujillo and Virginia Rood for their assistance. 






185 



The Indian population is young because of a birth rate that 
has been consistently twice that of the United States average. In 
1987 the crude birth rate for Indians and Alaska Natives was 
28.0 per 1,000 population compared to 15.7 for the general United 
States population. The median age of the Indian population was 
22.6 in 1980 as compared to 30 years for the United States (Indian 
Health Service, 1991a). Some traditional tribes, such as the Nav- 
ajo, had a median age as low as 18.8 in 1985 (Baris and Pineault, 
1990). Average socio-economic indicators for many tribes are 
quite poor (Hodgkinson, et al., 1990; Snipp, 1989), but within 
these aggregated data there is a wide range of individual situa- 
tions, from very poor, to a growing middle class, to some Indians 
who are quite well-to-do. Contemporary patterns of behavior 
vary widely from one Indian community to the next, based on 
a variety of factors including: the traditional folk culture of the 
tribal group and the relative rate of modernization and change 
that has occurred in recent decades (May, 1982). 

By definition, prevention of alcohol and other drug abuse 
among Indians is very promising. Because so many American 
Indians are young, prevention efforts might prove to be particu- 
larly successful in heading off bad habits, risky behavior, and 
addiction before they form or become entrenched. Furthermore, 
the fact that many Indians live in relatively concentrated areas 
(e.g., reservations or urban neighborhoods) may also be an 
advantage. Tribal identity and close kinship ties may also be 
tapped for prevention advantage. 

There are also many impediments to prevention as well. 
Some of these impediments have their roots in: the devastating 
history of Indian and U.S. Government relations over the past 
four centuries, the poor socio-economic status of many Indian 
families, and the lack of job and life opportunities that exists on 
many reservations and in the rural areas of the Western United 
States. Each of these factors creates barriers to prevention which 
challenge health and public health initiatives. 

From a research and evaluation perspective, the prevention 
of alcohol-related and alcohol-specific problems in American 
Indian communities has received neither adequate nor sufficient 
attention. Of the prevention efforts that have been undertaken 



186 



among Indians, few have been evaluated (Office for Substance 
Abuse Prevention (OSAP), 1990). When prevention evaluation 
has been done among Indians, process evaluation is most com- 
mon, and measures of outcome are rare. Furthermore, much of 
this evaluation research is not pursued with adequate vigor or 
rigor, and little has reached print in any medium, particularly 
scientific journals. Finally, very little prevention research carried 
out among Indians has been prospective in nature. This does 
not mean that prevention performed by various tribes, the Indian 
Health Service (IHS), the Bureau of Indian Affairs (BIA), State 
agencies, or others are not effective. It has not really been 
researched or evaluated adequately, and therefore one has lim- 
ited means of knowing whether it is effective. 

History of Alcohol Treatment and 
Prevention Among American Indians 

The prevention of alcohol and other drug abuse had received 
very little attention in Indian communities until the decade of 
the 1980s. Before that time, treatment was the most frequently 
discussed issue in alcohol circles. Many other public health prob- 
lems were the major foci of attention. The general paradigm of the 
pre-1980s was treatment and prevention of infectious diseases. 
Epidemics of infant diarrhea, tuberculosis, hepatitis, otitis media, 
and influenza took precedence over other health issues, and 
their solutions tended to be centered around hospital and clinic 
settings (Broudy and May, 1983). Prevention, particularly of 
behavior-related health problems, was not a high priority before 
the 1980s. The record of the Indian Health Service in lowering 
the rates of infectious diseases has, however, been outstanding 
(IHS, 1991a; Rhoades, 1987; Office of Technology Assessment 
(OTA), 1986). This has made a paradigm shift possible in recent 
years toward a greater emphasis on health promotion and disease 
prevention. 

The Office of Economic Opportunity (OEO) and the National 
Institute on Alcohol Abuse and Alcoholism (NIAAA) were the 
first Federal agencies to fund alcohol treatment programs for 
American Indians. These began in the late 1960s and early 1970s. 



187 



The Indian Health Service, however, did not have an office of 
alcoholism until 1976, when the ''mature' 7 NIAAA programs 
(those that had received five years of Federal funding) began a 
gradual transfer to the administrative control of IHS (IHS, 1986). 
The major focus of Indian alcoholism programs for many years 
was providing minimal treatment services to chronic alcoholics 
in most of the federally recognized reservations and tribal com- 
munities. Offering minimal treatment services is still the norm. 
Even those reservations with great need have inadequate 
resources for the problem at hand (Raymond and Raymond, 
1984; Mail, 1985; Silk-Walker, et al, 1988). 

Within Indian country today, and for at least the past seven 
years, health promotion and disease prevention are very much 
advocated. In a number of health promotion topics such as exer- 

j> : cise for diabetes prevention and control, smoking cessation, 

injury control, and others, prevention is advocated and being 
programmed (see May, 1988a for a review of some of these 

j •»- }'', programs for youth). Alcohol and other drug abuse prevention, 

however, appears a little slower to commence and gain momen- 
tum, except in a few special sub-topics (e.g., Fetal Alcohol Syn- 
drome) and among some particular sub-populations (e.g., 
schools). This, however, is not unusual for many groups and/ 
or communities in the United States. Ambivalence about alcohol 
is everywhere, and highly politicized discussions about treat- 
ment and prevention paradigms and policies consistently cloud 
the vision of, and planning for, the future (see Beauchamp, 1980). 
In this paper, an eclectic, objective public health approach 
will be taken. The major criterion for judgment is whether a 
prevention program, policy, or idea will reduce the toll taken by 
alcohol abuse (whether chronic, acute, or sporadic). There are 
many types of alcohol abuse and many paths to alcohol problems 
and addiction (Institute of Medicine, 1990). Shakespeare wrote 
in "Twelfth Night" (IIv.): 

1 x Some ore born greot 

Some ochieve greotness, 

ond some hove greotness thrust upon 'em. " 

(documentotion in Evons, 1968) 



188 



. 






The same can be said of many behaviors other than greatness, 
including alcohol abuse and addiction. Some people are born 
drunk (Fetal Alcohol Syndrome), some individuals and peer 
groups achieve alcohol abusive problems and addiction through 
purposive action, and others seem to fall victim to life's circum- 
stances and more passively develop alcohol-abusive patterns 
and addictions. 

Another way of stating this point is that alcohol problems 
are "heterogeneous." The Institute of Medicine (IOM) volume 
entitled Broadening the Base of Treatment for Alcohol Problems (1990) 
has pointed out that alcohol problems are heterogeneous: in 
etiology, in the course that the affected individuals and problems 
take, and in their presentation of consequences and needs for 
treatment and prevention. Therefore, the IOM advocated a termi- 
nological map and a broadly focused paradigm which covers 
drinking patterns from light to moderate to substantial and 
heavy. Furthermore, they indicate that these various drinking 
levels and styles are associated with particular types of problems 
from abuse and dependence which range in severity from mild 
to moderate to substantial to very severe (Institute of Medicine, 
1990, pp. 31-36). This document makes a strong case for the 
need to coordinate multi-faceted prevention programs with a 
variety of treatment programs. 

Therefore, programs of both prevention and intervention 
must be multiple and /or multifaceted to deal with the different 
paths to alcohol problems and the manifestations thereof. Fur- 
thermore, a variety of approaches are necessary to deal with the 
many controllable or manipulable aspects of the problem as 
presented by the various hosts, agents, and environments of 
alcohol abuse. Different types of abuse are associated with vari- 
ous manifestations of the problem and require different pro- 
grams of prevention. 

Four Common Drinking Styles 

Some studies have described a variety of drinking styles among 
most American Indian groups (Weisner, et al., 1984; Levy and 
Kunitz, 1974). Most frequently mentioned are four: abstinence, 
recreational, anxiety, and moderated social drinkers (Ferguson, 



189 



• 



1968; May, 1982, 1989a). Of these four styles only two are, by 
definition, linked to problems: the recreational and the anxiety. 
Abstinence, very common among many tribes (see May, 1989a), 
particularly among the middle-aged and older, obviously causes 
no alcohol-related problems. Similarly, many acculturated Indi- 
ans tend to drink as do others in the occupations, organizations, 
or strata of society to which they are attached (see Levy and 
Kunitz, 1974; Liban and Smart, 1982). Many Indians, therefore, 
tend to practice a moderated or light social drinking style that 
produces few or no problems related to morbidity, mortality, 
arrest, or other health or social problems. 

Ferguson (1968) described the recreational and anxiety drink- 
ers among the Navajo, and these types are very common among 
most Indians and Alaska Native groups. The recreational drinker 
is typically a young male who drinks with friends (predomi- 
nantly male, but mixed as well) for weekends, parties, special 
occasions, and other social events. As with other groups of young 
persons, drinking and intoxication are important for social cohe- 
sion and are generally highly valued. Recreational drinking 
among Indian groups of many tribes may only be different from 
other groups in the United States in matters of degree and cul- 
tural meaning. As described by many authors, Indian recre- 
ational drinking is more rapid, more forced, and the ' 'bouts' ' 
are extended over long nights, entire weekends, and for other 
lengthy periods (Hughes and Dodder, 1984; Lurie, 1971; Dozier, 
1966: Savard, 1968; and Weisner, et al, 1984). Very high blood 
alcohol concentrations are commonly found in Indians who prac- 
tice this style of drinking. 

The recreational drinker is more fitting of the term alcohol 
abuser, while the anxiety drinker is more akin to an alcoholic. 
Anxiety drinkers are older, drink chronically, are more solitary, 
and are generally physically addicted to alcohol. They generally 
drink cheap wine and beer and supplement with hard liquor, 
but will consume most any alcoholic beverage available. They 
also turn to non-beverage items that contain alcohol (e.g., hair 
spray, after shave, Lysol) when necessary or even for a special 
"kick." Anxiety drinkers are mostly unemployed, live in border 
towns and skid row areas, and are not usually associated with 



190 



the mainstream society of their tribe or of Western society. Most 
anxiety drinkers are ostracized to a great degree, whereas the 
recreational drinkers may be in mainstream society and only 
associated with abusive peer clusters when drinking. 

The above two patterns represent at least two types of alcohol 
abusive or alcohol problem-generating styles that must be 
addressed bv prevention and treatment programs in most tribes. 
If a prevention treatment program is onlv addressing one tvpe, 
it is an incomplete program. Furthermore, there is age variation 
associated with all drinking styles, and there mav be other prob- 
lem drinking patterns in communities that exist in addition to, 
or in place of, these types. The point is that different drinking 
styles dictate different prevention intervention needs and 
approaches (see May, 1986). 

Introduction to the Prevention 
Literature 






As documented below, the literature on prevention among 
American Indians is not extensive, but it is larger than manv 
might suspect. Many professionals and lav people alike fre- 
quently seem to assume that the published literature on Indian 
health issues is in general small. Furthermore, prevention efforts 
were, until recently, believed bv manv to be rare among Indians. 
Review articles on prevention of drug abuse among Indians 
have generally concluded that alcohol and other drug-related 
problems affect a significant number of American Indians, that 
a great deal needs to be done in prevention among .American 
Indians, that the extremely young median age of Indian popula- 
tions is an advantage for prevention, and that treatment and 
rehabilitation would not alone be sufficient, even with services 
of the highest caliber (see Westermeyer and Peake, 1983; Mail, 
1985; Beauvais and LaBoueff , 1985; Mav, 1986, 1988b; Silk-Walker 
et al, 1988; OSAP, 1990). Furthermore, several reviews have 
called for a greater emphasis on drug abuse prevention. This 
area, then, is awaiting further development and documentation 
of its effectiveness. 



191 



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Mq/or Prevention-Review Documents on 
Indians 

In the past decade and one half, several prevention theory/ 
advocacy and literature review papers and monographs particu- 
lar to American Indians have been published. Some cover drug 
abuse exclusively while others are predominantly from a mental 
health perspective. 

An early document advocating a prevention approach to 
alcohol problems was a report from the 1977 Indian Health Ser- 
vice (IHS) Task Force on Alcoholism that was convened in 1969 
and 1970. The report, titled Alcoholism: A High Priority Problem, 
started with a disease definition and emphasized treatment; but, 
the report also addressed alcohol-related problems as behaviors 
amenable to broader activity in the community and society. 
Besides the standard medical services, social services, and psy- 
chiatric care, this document called for health education for pre- 
vention, planning, and an emphasis on new community relation- 
ships related to alcohol programs and problems. Planning was 
emphasized on an interagency and a community-wide basis to 
support and complement medical and psychiatric care (IHS, 
1977). 

In a monograph that was produced and distributed from 
the Colorado State University Psychology Department, Beauvais 
(1980) reviewed the extant literature on alcohol and drug use 
among Indian youths and made explicit suggestions for Indian 
community prevention and health education programs. This 
monograph is unique among the prevention review documents 
covered in this section in that it has a stronger emphasis on 
drugs other than alcohol. Based on the literature, Beauvais (1980) 
presents several "ways to help" for prevention. These include: 
parent, student and school staff education, hospital-based inter- 
ventions, the use of role models, and the application of traditional 
cultural and craft activities for prevention. Finally, the mono- 
graph contains detailed and valuable generic information about 
the effect of a variety of drugs on the human body and human 
functioning. 

In another ground-breaking monograph, one that is primarily 
concerned with mental health issues, prevention is the sole topic. 



192 



Edited by Manson (1982), the monograph, New Directions in Pre- 
vention Among American Indians and Alaska Native Communities, 
contains 15 articles dealing with a variety of issues related to 
Indian mental health. Specific topics include general prevention 
research theory and practices applied to American Indian com- 
munities, primary prevention, evaluation of prevention efforts, 
training for prevention efforts, and the role of cultural networks 
in prevention. All of this is in addition to a variety of mental 
health topics, including alcohol abuse. Forty-six articles on pre- 
vention of alcohol and drug abuse problems (mostly primary 
prevention) are identified in the introductory chapter by Manson, 
Tatum, and Dinges (1982). The fact that mental heath and drug 
abuse issues are intimately related is underscored by this mono- 
graph. Further, the monograph represents an excellent resource 
for reviewing the issues, theory, and techniques of prevention b 

among American Indians and Alaska Natives. Concepts and 
approaches in this work might be brought to bear on alcohol- 
specific problems. But the reader should bear in mind that the 



prevention of alcohol and other drug abuse requires somewhat 



different approaches than does the prevention of certain psychi- 



atric problems. This will be evident in a later section of this paper. 

Trimble (1984) concentrated on alcohol and drug abuse pre- 
vention research both by reviewing the literature and concepts 
and by making recommendations for needed direction in future 
prevention research. His work draws from 89 literature sources 
and makes ten recommendations for future primary prevention 
research projects, six recommendations for secondary preven- 
tion, and inquiry about research at the tertiary level (prevention 
of further medical, social, and psychological problems once an 
alcohol problem is manifest). Tertiary level research was found 
by Trimble to be virtually non-existent. 

In 1985 Beauvais and LaBoueff published a paper that 
reviewed the theoretical issues related to drug and alcohol abuse 
prevention among Indians. This paper provided theory and data 
upon which to base such programs, reviewed approaches to 
prevention that begin from within the community, and provided 
guidelines for community action in prevention. Emphasis in this 
paper is placed on community activity that should be undertaken 



193 



"... 



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on a step-by-step basis in prevention. The authors explicitly state 
that prevention activity should not use "top down" approaches 
initiated from the outside. 

In a previous review of prevention programs for Indians, 
May (1986) addressed both treatment and prevention literature 
from an evaluative perspective. Treatment programs in Indian 
country that had been evaluated before 1984 were found to have 
no greater success than other treatment programs elsewhere. The 
range in success rates, using various definitions, was from 19% to 
40%, which left room for improvement (May, 1986). Furthermore, 
there were (and still are) many drug and alcohol abuse problems 
that were not addressed by most Indian-oriented treatment and 
prevention programs (May, 1986; Weibel-Orlando, 1984, 1989; 
Weisner, Weibel-Orlando, and Lang, 1984). Many areas of alco- 
hol-related morbidity and mortality (motor vehicle crashes, 
trauma, suicide, and homicide), women's drinking issues, drink- 
ing among the dropout and out-of-school population, and fetal 
alcohol exposure were salient examples of under-addressed 
issues cited in this article. The modal alcoholism programs for 
Indians were found to target middle-aged, adult males with 
chronic drinking problems (anxiety drinkers). As in the early 
1980s, treatment is still emphasized in most programs, leaving 
little emphasis, time, or resources for prevention. 

A final review document is a monograph written by Candice 
Flemming and others and published by the Office for Substance 
Abuse Prevention (OSAP, 1990). This monograph reviews 80 
articles identifying 60 preventive interventions carried out 
among Indians. It further addresses cultural, historical, commu- 
nity, and research issues important to Indians. In addition to the 
literature review, this monograph contains brief descriptions of 
52 different programs or approaches described in the literature. 
It also contains a section that provides an analysis of 16 Indian 
and Alaska Native programs funded by OSAP in 1990. Finally, 
the monograph summarizes data from a telephone survey with 
prevention project managers of Indian programs. This mono- 
graph is a complete and valuable review of the prevention litera- 
ture on drug abuse (and a number of combined drug abuse/ 
mental health programs). It is a snapshot of the state of the 



194 



art in several existing prevention programs among American 
Indians and Alaska Natives. 

The OSAP (1990) monograph concludes with seven recom- 
mendations. These recommendations are: (1) more needs to be 
known about how prevention programs survive for the long 
term, (2) the relationship between traditional culture and drug 
use needs to be studied further, (3) every project should be 
"rigorously" evaluated, (4) more should be learned about the 
role of peer clusters in drug abuse, (5) general community devel- 
opment can make prevention efforts more effective, (6) more 
comprehensive approaches are increasing and should be encour- 
aged, yet broader economic and environmental risk factors are 
rarely addressed, and (7) more focus must be given to community 
norms concerning drug abuse and how change is accomplished 
and sustained. The monograph also reports that most prevention 
programs are school-based (OSAP, 1990, p. 39, Table 6) and 
that evaluation of most programs was lacking. Only 56% of the 
programs surveyed had research designs with both process and 
outcome evaluation. 

The above themes presented in the review papers and mono- 
graphs should serve as orientation and background for the reader 
of this paper. They very succinctly capture some of the ascendant 
and current issues in prevention of alcohol and other drug abuse 
among Indians today. 



Prevention Literature: A Catalogue 
of Recently Published Sources 

Prior to 1980, much of the literature which existed on American 
Indian alcohol and mental health issues were either unpublished 
or published in obscure places such as committee reports, center 
documents, or conference proceedings (Mail and McDonald, 
1980). In some of these works prevention programs were men- 
tioned, and in several cases presented in a detailed fashion. But 
overall, prevention ideas were neither widely distributed, nor 
did they receive adequate attention. In the major bibliography 
on alcohol use and abuse among American Indians by Mail 
and McDonald (1980), there are 25 citations in the index under 






195 





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prevention of alcohol problems, eleven for prevention of suicide, 
and two for prevention of delinquency (p. 344). Of the alcohol 
prevention citations, 52% are papers that were unpublished and 
a major focus on prevention was not really evident in 42% of those 
papers. These works instead focused on issues (e.g., treatment or 
service delivery) or topics (e.g., suicide, self-esteem, and mental 
health) other than primarily on the prevention of alcohol abuse 
problems. 

In preparing to write this paper, a literature search was initi- 
ated through MEDLINE on the topic of "prevention of alcohol- 
ism/substance abuse among Native Americans/' The search was 
from 1982-1992, and 26 articles were identified. This search 
formed the basis of the review and discussion in this paper, 
along with the literature identified in the previously mentioned 
works by Manson (1982), Trimble (1984), OSAP (1990), and oth- 
ers. As a "key word" in the literature, then, prevention is not 
manifest to any great degree in the area of alcohol abuse among 
American Indians. 

Presented below in figures 9-1 through 9-3 are listings of 
articles and other prevention-oriented works that should be use- 
ful to those researching and pursuing applied programs in pre- 
vention. An attempt has been made to focus as completely as 
possible on alcohol and other drug abuse programs that are 
primarily or substantially prevention oriented. There was a con- 
scious attempt to exclude programs that are primarily oriented to 
mental health and psychiatric problems or those that exclusively 
focused on alcoholism treatment. The emphasis in these figures 
is on the three levels of prevention from tertiary to primary. 1 
Because some programs have diverse elements that span all three 
levels, categorization was difficult. 

Tertiary Level Prevention 

In figure 9-1 the programs that emphasize tertiary strategies with 
Indian alcohol abuse are covered. As Trimble (1984) indicated, 
it is difficult to find tertiary programs described in the alcohol 
literature on Indians. One could include many more alcoholism 
treatment programs here, but that is not the intent. This paper 
is written to highlight those with the greatest emphasis on tertiary 



196 



Figure 9-1. Tertiary Level Prevention of Alcohol and 
Substance Abuse Problems Among American Indians 


Author, Date 


Topic; Target Groups 


Shore and Von Fumetti, 1972. 


Three adult alcohol treatment 
programs; Northwest Indians. 


Wilson and Shore, 1975. 


One adult alcohol treatment 
program; Northwest Indians. 


Weibel-Orlando, 1989. 


Description of 26 adult alcohol 
treatment programs; Far West. 


Ferguson, 1968; 1970; 1976; 
Savard, 1968. 


Etiology and description of 
treat-ment and intervention 
(including antabuse) with 
chronic adult alcoholics; 
Navajo. 


Price, 1975; 
Hagan, 1976. 


These two articles advocate 
new policy in the criminal 
justice system which 
decriminalizes alcohol 
intoxication and seeks 
therapeutic alternatives; 
Canadian Indians. 


Westermeyer and Peake, 1983. 


Etiology and evaluative follow- 
up of adult alcoholics; 
Chippewa. 


Albaugh and Anderson, 1 974; 

Pascarosa and Futterman, 

1976; 

Blum, Futterman, & Pascarosa, 

1977. 


The use of Native American 
church rituals and the 
sacramental use of Peyote to 
treat alcoholism among adults; 
Plains tribes. 


Masis and May, 1991. 


Fetal Alcohol Syndrome 
prevention by focusing on 
chronically alcoholic women at 
high risk for causing FAS; 
Navajo. 



prevention, efforts that minimize the adverse consequences of 
severe alcohol abuse once it is manifest. The above articles repre- 
sent this thrust in several ways. The first three listings, Shore 
and Von Fumetti (1972), Wilson and Shore (1975), and Weibel- 
Orlando (1989) describe the typical methods used in Indian alco- 



197 



hoi treatment programs and the tertiary prevention issues that 
are important to consider with adult Indian alcoholics. These 
articles show a thrust toward managing the effects of alcoholism. 
Additionally, many other alcohol-related tertiary prevention 
issues are linked to other areas of health such as injury, disability, 
and protection of the alcohol abuser's family, but these are 
beyond the scope of this paper. 

Not exclusive of the scope of this paper, however, are the 
articles by Ferguson (1968, 1970, 1976) and Savard (1968) which 
very completely describe the use of antabuse, arrest diversion, 
milieu change, and other tertiary methods of prevention and 
intervention with chronic alcoholics. Price (1975) and Hagan 
(1976) have addressed decriminalization, arrest diversion, and 
arrest-keyed therapy as tertiary solutions to excessive arrest rates 
for alcohol intoxication among some Indians. 

Westermeyer and Peake's (1983) article is unique, for the 
ten-year follow-up methodology is not only the longest in the 
Indian alcohol literature, but also is insightful for factors related 
to chronic alcoholism. The factors studied included (1) longevity, 
(2) social, occupational, and cultural survival, and (3) drug abuse 
outcomes and patterns for 45 people who had been treated for 
chronic alcoholism. Given the high relapse rate for alcoholics, 
these are vital issues in tertiary prevention. 

Also included in the literature are three articles describing 
the therapeutic efficacy of providing the values, beliefs, structure, 
and rituals of the Native American Church to treat and prevent 
further problems from alcoholism. Albaugh and Anderson 
(1974), Pascarosa and Futterman (1976), and Blum, et al. (1977) all 
see Native American church practices and peyote as therapeutic 
agents that can treat problems with alcoholism. The latter two 
articles, however, seem to emphasize the pharmacology more 
than Albaugh and Anderson (1974). 

The final article in figure 9-1, Masis and May (1991), describes 
a fetal alcohol syndrome prevention program in Arizona that is 
highly focused on chronic alcoholic women. The tertiary goals 
are to prevent future alcohol-damaged children, Fetal Alcohol 
Syndrome (FAS) or Fetal Alcohol Effect (FAE), from mothers 
who have already had one damaged child or are drinking heavily 



198 



. 






while pregnant. This is done by providing counseling, support, 
birth control, and treatment for alcoholism. 

Secondary Level Prevention 

In figure 9-2 the more recent secondary prevention resources are 
listed. As is evident, there are many more secondary prevention 
programs described in the recent literature (N = 38) than other 
types of programs. This has not always been the case, for in the 
1960s several of the more influential articles (e.g., Dozier, 1966 
and Stewart, 1964) emphasized primary prevention through 
large-scale social and community-wide influences. 

The secondary prevention articles are very useful and pro- 
vide one with an excellent set of complementary approaches for 
working with aggregates and /or groups within Indian commu- 
nities who are high risk by definition (teenagers) or by demon- 
stration of the earliest signs of alcohol use and abuse. The focus 
in secondary prevention is on these subgroups or aggregates and 
individuals within them rather than on the entire community, 
environment, or structural conditions promoting or discouraging 
drug abuse. 

Of all the areas of prevention for American Indians, the sec- 
ondary level programs provided for youths have been the most 
common. Although only a few of these programs have been 
rigorously evaluated, they have been researched and evaluated 
better than many Indian treatment programs and other levels of 
prevention. The empirical research that lays the theoretical and 
scientific groundwork for these programs is very extensively and 
rigorously researched, especially studies of alcohol and other 
drug abuse among Indian youth. 

The first 15 articles in figure 9-2 are excellent resources for 
planning prevention, for they are theoretically sound and based 
on literally tens of thousands of survey responses from individual 
youths. These surveys have been done all over the United States. 
The work of Oetting, Beauvais, Edwards, Swaim, and colleagues 
at Colorado State University has been ongoing for two decades, 
as has that of Winfree, Griffiths, and colleagues, although on a 
much more modest scale. All of the overview articles listed in 
figure 9-2 provide a very sound and tight theoretical base for 



199 



S3 * 

* ■ c 






Figure 9-2. Secondary Level Prevention Literature on 
Alcohol and Substance Abuse Among American Indians 


Author, Date 


7bp/c; Target Group(s) 


(Overview Articles) 


Oetting and Beauvais, 1 989; 
1991. 


Etiology of Alcohol and 
Substance Abuse applied to 
prevention techniques; Indian 
youths. 


Beauvais, Oetting, and 
Edwards; 1985a; 1985b; 1988. 


Correlates and trends of 
substance abuse for 
intervention/prevention; Indian 
youths. 


Oetting, Swaim, Edwards, and 
Beauvais, 1989. 


Places emotional distress in the 
proper prevention context; 
Indian youths. 


Swaim, et al., 1993. 


Cross-cultural comparisons for 
insight for prevention programs; 
Indian youths. 


Bach and Bornstein, 1981. 


A social learning rationale 
applied to potential Indian 
alcohol abuses; Indian youths 
and adults. 


Winfree and Griffiths, 1983a; 
1983b; 1985; Winfree et al., 
1989; and Sellers and Winfree, 
1990. 


Social learning theory, 
differential association theory, 
and trends of alcohol and 
substance abuse with 
prevention applications; Indian 
youths in the Northwest. 


Hoover, McDermott, and 
Hartsfield, 1990; and Boyle and 
Offord, 1986. 


Alcohol, tobacco, and 
smokeless tobacco use 
patterns for designing 
prevention programs; 
Canadian Native youths. 


(Secondary Prevention Within Alcohol, Mental Health Programs) 


Silk-Walker, Walker, and 
Kivlahan, 1988. 


A survey of a number of the 
secondary and tertiary 
prevention issues in an alcohol 
treatment program; Alcohol 
abusing adults. 


Levy and Kunitz, 1987. 


Identifies factors of high risk for 
suicide and alcohol problems 
for secondary prevention; Hopi. 



200 



Figure 9-2. Secondary Level Prevention Literature on 
Alcohol and Substance Abuse Among American Indians 
(continued) 


Author, Date 


Topic; Target Group(s) 


Shore and Kofoed, 1984. 


Reviews the premise of five 
secondary prevention 
programs for community 
prevention success; Adults. 


Kahn and Stephan, 1981; 

Kahn and Fua, 1 985; 

Ward, 1984; 

Fox, Manatonabl and Ward, 

1984. 


These four articles describe how 
alcohol abuse prevention can 

be undertaken and effective as 
a community-based mental 
health/suicide prevention 
program; Tono O'Odam and 

Canadian Indian adults. 


Parker, et al„ 1991. 


An Indian-culture based 
prevention program to build 
self-esteem and reduce 
substance abuse; Northeastern 

Indians. 


(School-based Programs) 


Indian Health Service, 1987. 


A description and summary of 
the several hundred school- 
based alcohol abuse 
preventive programs of the 
Indian Health Service; Indian 
youths and parents. 


Manson et al„ 1989. 


Alcohol consumption 
correlated with suicide 
attempts and 22% of all school- 
based suicide prevention 

programs have alcohol 
prevention components; 
Youths. 


Duryea and Matzek, 1990. 


Prevention among elementary 
school children is explained 
through resisting peer pressure; 
Pueblo. 


Okwumabua, J. O., 
Okwumabua, T. M., and 
Duryea, E. J„ 1989. 


Health decision making was 
found to be quite efficacious 
among seventh graders, 
indicating knowledge of the 
consequences of their 
behavior; Pueblo. 



201 



1 1 

■ 



Figure 9-2. Secondary Level Prevention Literature on 
Alcohol and Substance Abuse Among American Indians 
(continued) 


Author Date 


Topic; Target Group(s) 


Bernstein and Woodall, 1987. 


Perceptions of riskiness 
increased with a program of 
health education and life 
experience; NM Indians, in 
grades 6-8. 


Murphy and DeBlassie, 1984. 


Counselor intervention 
strategies are emphasized; 
Mescalero Apache elementary 
school children. 


Scott and Meyers, 1988. 


Fitness training is found to 
stabilize alcohol and drug use; 
Canadian Indian youths ages 
12-18. 


Schinke, Mancher, et al., 1989; 
Schinke, Schilling, et al., 1989; 
Schinke, et al., "1 988; 
Gilchrist, et al., 1987; 
Schinke, et al., 1985. 


American Indian youth are 
found to benefit from skills 
training and health education. 
Results show the youths to have 
greater knowledge of drug 
effects, better peer pressure 
management and lower rates 
of substance use; Northwest 
Indian youths. 


LaFromboise and Rowe, 1983. 


Bi-cultural competence and 
assertiveness are improved by 
skills training in a culturally 
appropriate manner; Indian 
youths. 


Carpenter, Lyons, and Miller, 
1985. 


A peer managed self-control 
program successfully taught 
responsible drinking to 
teenagers and the results held 
up for 1 2 months; Indian 
teenagers. 


Davis, Hunt, and Kitzes, 1989. 


A school-based teen center 
dispensing integrated health 
services including alcohol 
education and counseling is 
described; Pueblo teens. 



202 






prevention planning. The bulk of this literature is converging 
on a common set of variables, theories, and approaches that 
clearly describe the problem and lay out the most likely 
approaches for prevention. Most works focus on alcohol and 
other drug abuse, but a growing body of work is now building 
on tobacco as well (Hoover, et al., 1990; Boyle and Offord, 1986). 
Reviewing the substantive highlights of these works is impor- 
tant here. In the literature, Indian youths generally report that 
they use alcohol as frequently as or more frequently than other 
youths in the United States. For example, by the 12th grade, 
lifetime prevalence of alcohol use is quite high: for Indian males, 
96%, and females, 92% (Oetting and Beauvais, 1989). National 
studies of U.S. adolescents show similar use patterns in that 92% 
of all high school seniors report having used alcohol at least 
once (NIAAA, 1990). But the major difference is found in mea- 
sures dealing with age at first involvement and degree of involve- 
ment. According to the major researchers in this area (Beauvais, 
Oetting, and Edwards, 1985b; Oetting, Beauvais, and Edwards, 
1988), the age at first involvement with alcohol is younger for 
Indian youths, the frequency and amount of drinking are greater, 
and the negative consequences are more common (see also 
Hughes and Dodder, 1984; Forslund and Cranston, 1975; For- 
slund and Myers, 1974). Oetting, Beauvais, and colleagues have 
found that at all ages and grades a greater percentage of Indian 
youth are more heavily involved with alcohol than are non- 
Indians (Oetting and Beauvais, 1989). Several studies indicate 
that this is both encouraged and expected among many peer 
groups as the "Indian thing to do" (Winfree and Griffiths, 1983a; 
Lurie, 1971). Therefore, some drinking at a young age prior to 
the 12th grade is quite common among Indian youths as it is 
with other United States youths. By 12th grade, 80 percent of 
Indian youth are current drinkers, but there is some variation 
from reservation to reservation (see May, 1982). Severity mea- 
sures show that Indian youths who drink are more likely to 
report having been drunk and to have "blacked out" (Oetting 
and Beauvais, 1989). Just as United States high school data 
showed an increase in drinking and marijuana use through 1980, 
and subsequent declines after 1980, the Indian patterns over time 



203 






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are similar. That is, Indian youths have reported less use of drugs 
and alcohol in recent years (Oetting and Beauvais, 1989; Winfree 
and Griffiths, 1985), but a decline in heavy users has not occurred. 
Heavy use among Indian youth has remained steady at 17 to 
20% (Beauvais, 1992a). 

Those youths who are most likely to abuse alcohol are those 
who associate with alcohol and drug abusing "peer clusters." 
Furthermore, alcohol-abusing Indian youths are those who do 
not do well in school, who do not strongly identify with Indian 
culture, and who come from families who also abuse alcohol 
(Guyette, 1982). Oetting and colleagues (Oetting and Beauvais, 
1989) concur, for their findings characterize abusers as having 
poor school adjustment, weak religious /spiritual foundations, 
poor family and peer group associations, and little hope for the 
future. Conversely, Indian youths with strong family attach- 
ments, where culture and school are valued and abusive drinking 
is neither common nor positively valued, tend to be less likely 
to get seriously involved with alcohol, marijuana, and inhalants, 
the "big three" drugs common for drug-abusing Indian youths. 
Low self-esteem, depression, anxiety, and other negative emo- 
tional states are not influential in alcohol abuse among Indian 
youths (Oetting and Beauvais, 1989; Oetting, et al., 1988). Bicul- 
turalism (the ability to function well in both tribal, Indian society 
and the modern, Western world) is a real strength for Indian 
youths, for it is a trait that is not associated with alcohol abuse or 
other negative traits that predispose youths to alcohol problems 
(Oetting and Beauvais, 1991). In their most recent works these 
same researchers emphasize resocialization (the learning or 
relearning of modes of adjustment to life that are drug free) in 
the family, schools, peer groups, and religious institutions as 
preventive of drug abuse among Indian youths (Swaim, et al., 
1993; Beauvais, 1992b). 

The second main grouping of articles in Figure 9-2 concerns 
secondary drug abuse prevention carried out within the context 
of mental health programs. Many, if not most, of all problems 
that come to the attention of mental health programs involve 
co-morbidity with alcohol and other drug consumption (May, 
1988b). Therefore, drug abuse prevention has often been devel- 



204 



oped in mental health programs. Of the eight articles of this 
nature highlighted in figure 9-2, six are in a mental health/ 
suicide prevention context, one is within an alcoholism treatment 
context (Silk- Walker, et al., 1988), and two are in a larger commu- 
nity mental health initiative context (Shore and Kofoed, 1984; 
Parker, et al., 1991). These articles underscore the many possibilit- 
ies for initiating prevention of all types from mental health and 
alcoholism programs, an effort that has been too rare in the past 
in many Indian communities. 2 

The final group of articles in figure 9-2 concerns the school- 
based programs. Most of the prevention programs aimed at 
American Indians in recent years have been school-based pro- 
grams that emphasize the previous information about the effects 
and consequences of drug abuse. Programs such as "Here's 
Looking at You," "Project Charley," and "Babes" have been 
used in many Indian communities both on and off reservation 
(IHS, 1987). Aimed at children from elementary school through 
high school, these programs are implemented in a variety of 
ways by staff, faculty, and counselors. Parent involvement is 
generally not a major component of these programs, and some 
say the influence seldom goes outside of the school grounds. 
The effectiveness of these programs has been studied and pub- 
lished very infrequently given the fact that literally thousands 
of them have been undertaken. The fifteen articles here represent 
the evaluation of only a few of the programs ongoing in Indian 
community schools. Furthermore, these programs evaluated and 
described in the literature are generally of more intensity and 
of a different modality than the mainstream programs cited 
above. One should consult the Indian Health Service (1986, 1987) 
documents for details on the most frequently used school-based 
prevention efforts. 

The consistent themes in the school-based prevention pro- 
grams are building bicultural competence (LaFromboise and 
Rowe, 1983), increasing self-esteem and self-efficacy (IHS, 1987), 
improving resistance and judgment skills, particularly in the face 
of peer pressure (Duryea and Matzek, 1990; Schinke, Mancher, 
et al., 1989; Schinke, et al, 1988; Gilchrist, et al., 1987), and increas- 
ing the perception of the riskiness of alcohol and drug use (Bern- 



205 



stein and Woodall, 1987). Certainly the current etiological litera- 
ture supports these efforts if taken in the proper context. That 
is, building self-esteem alone will not solve the drug use and 
abuse problems. Building new perceptions, values, skills, and 
support systems along with self-esteem may be the key. There- 
fore, these programs must also have an effect on the socio-cul- 
tural aspects of life and the existence of abusive peer clusters in 
the life of these youths (Neucomb and Bentler, 1989). This can 
be accomplished by either direct or indirect influence, but the 
socio-cultural aspects must be addressed, not just the mental 
health and psychological issues (Oetting and Beauvais, 1989). 

Nevertheless, the articles which document school-based pre- 
vention are very useful and can be used as guides and models 
for others in the future. Furthermore, long-term follow-up of 
the adolescents who participated in these programs should be 
pursued aggressively in the coming years, particularly after they 
leave school and move into adulthood. Eventually, studies of 
prevention among Indian youth will need to build a strong litera- 
ture based on long-term outcome evaluation that will pinpoint 
factors associated with both a lack of drug abuse and overall 
success in life (Neumann, et al., 1991). 

Primary Level Prevention 

Moving now to figure 9-3, the primary prevention literature is 
listed. From overviews of the approach to specific changes in 
communities to prevent alcohol abuse, this literature is beginning 
to grow in size and specificity. 

Community-based and primary prevention in general has not 
been pursued to any great degree, for the planning of community 
action on health problems is also a relatively new approach in 
many Indian communities (OSAP, 1990). Only in the last 15 years 
have most reservations been able to begin and to staff programs 
as basic as their first emergency medical services. Therefore, it 
is little wonder that the focus on community-wide prevention 
is new. Other problems were much more pressing in the past. 
In the 1980s, however, interest in prevention programs was built. 
This is especially true regarding prevention of behavior-related 
health programs, such as diabetes (Leonard and Leonard, 1985), 



206 



Figure 9-3. Primary Level Prevention of Alcohol and 
Substance Abuse Problems Among American Indians 



Author date 



Topic; Target Area 



(Overview) 



Rhoades et al., 1988; 
Indian Health Service, 1986. 



May, 1986. 



OSAP, 1990. 



Mail, 1985; 

Mail and Wright, 1989. 



Beauvais and LaBoueff, 1985. 



Marum, 1988. 



Beauvais, 1992b. 



Maynard and Twiss, 1 970. 



Describes the IHS programs 
and/or philosophy in the 
treatment and prevention of 
alcoholism for over 300 
reservations; U.S. Indians. 

A overview of the existing 
alcohol abuse problems, 
especially mortality, and a call 
for comprehensive prevention 
programs; U.S. Indians. 

A comprehensive review of the 
literature, prevention programs 
instituted past and present, and 
recommendations; U.S. Indians. 

Two works on the concepts 
and necessity of designing 
comprehensive prevention from 
the indigenous cultural energies 
and point of view; U.S. Indians. 

Prevention must come from the 
ground up and the process is 
described; All Indians. 

Community mobilization 
through workshops and training 
is described; Alaska Native 
communities. 

A model of substance abuse 
prevention variables (peer, 
psychological, social structure, 
and socialization factors) are 
presented; Indian youths. 

A fully comprehensive study 
and plan for primary prevention 
of mental health and 
substance abuse problems; 
Oglala Sioux. 



207 



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■£: 










(1) 






■ 


'«.,.. 




. 


*•. . 






fc) 




' .': : 






■ 









Figure 9-3. Primary Level Prevention of Alcohol and 
Substance Abuse Problems Among American Indians 
(continued) 


Author Dote 


Topic; Torget Group(s) 


(Alcohol-Related Injury Control) 


May, 1989b. 


A literature review and 
overview of alcohol and motor 
vehicle crashes among Indians 
with primary, secondary, and 
tertiary prevention suggestions; 
All Indians and Alaska Natives. 


Smith, 1991; 
IHS, 1990. 


An article and a data 
monograph which lay out the 
details of the Indian injury 
problem, the IHS initiative to 
implement primary prevention 
and tools for prevention; All 
Indians and Alaska Natives. 


Macedo, 1988. 


A description of community- 
wide change and prevention 
of alcohol-related social 
trauma and injury in two 
communities and a framework 
for analysis are presented; 
Canadian Indians. 


(Fetal Alcohol Syndrome) 


May and Hymbaugh, 1989. 


Describes a nation-wide 
primary prevention program 
directed at Fetal Alcohol 
Syndrome and using public 
education through the training 
of trainers; All Indians and 
Alaska Natives. 


May and Hymbaugh, 1983. 


A comprehensive research, 
clinical assessment, and 
primary prevention program for 
a number of tribal communities 
is described; Southwestern 
Indians. 


Plaisier, 1989. 


A primary and secondary 
prevention program using 
health education as a vehicle; 
Indians in Michigan. 



208 



Figure 9-3. Primary Level Prevention of Alcohol and 
Substance Abuse Problems Among American Indians 
(continued) 



Author Date 



Topic; Target Group(s) 



(Prevention Based on Policy and Laws] 



May, 1975; 1976; 1977. 



Two articles and a doctoral 
dissertation which examine 
alcohol legalization/prohibition 
policies on reservations and the 
effects of these laws on 
alcohol-related mortality; 
Northern Plains tribes. 



Back, 1981 



Bellamy, 1984. 



An article which evaluates the 
effectiveness of prohibition on 
the Navajo reservation and 
calls for new policy as a 
preventive measure; Navajo, 

A doctoral dissertation which 
compares the behavioral and 
attitudinal characteristics of 
youths growing up on a pro- 
hibitionist, a long-term 
legalization, and a recently 
legalized reservation; Plains 
Indians. 



■ 



May and Smith, 1988. 



A survey of opinions about 
alcohol and alcohol policy with 
subsequent recommendations 
for alcohol policy and 
prevention; Navajo. 



May, 1992. 



A comprehensive survey of 
alcohol control policy and 
primary prevention measures 
from all over the world applied 
to Indians and border town 
communities; All Indians and 
Alaska Natives. 



209 






car seat protection (May, 1988a), and one successful community- 
wide alcohol prevention program in Alkali Lake, British Colum- 
bia ("The Honour of All," a documentary film). 

The success of one primary prevention effort on any problem 
often generates interest in prevention topics of other types. Atten- 
tion is, therefore, only recently being turned away from treat- 
ment, intervention, and other levels of prevention to primary 
prevention. The focus for solving health problems is leaving the 
once deadly (but now tamed to a significant degree) infectious 
diseases and turning toward other morbidity and mortality prob- 
lems. The epidemiologic transition (Broudy and May, 1983) has 
made behavior-related health problems more obvious and more 
important on the list of health priorities. Alcohol abuse and 
related behavioral health concerns are now issues that can be 
discussed and eventually addressed in a number of Indian com- 
munities (IHS, 1986). The recent OSAP (1990) evaluation of 
v. Indian drug abuse programs concludes by calling for more com- 

prehensive, community-based prevention programs that are rig- 
orously evaluated. 



The overview articles and monographs in figure 9-3 are excel- 






lent at putting forth the rationale and philosophy of primary 
prevention. The Rhoades, et al. (1988) article and, more particu- 
larly, the Indian Health Service (1986) monograph are in many 
ways a call to commence broader programs of prevention, partic- 
ularly those that emphasize primary prevention via community 
change. Getting a large and complicated bureaucracy such as 
the Indian Health Service moving forcefully in this direction for 
alcohol abuse prevention, however, will take time. The May 
(1986) article calls for primary prevention of alcohol abuse, and 
particularly for a focus on reducing the toll of alcohol-related 
sequelae (mortality and morbidity) through social policy, envi- 
ronmental change, and broad-based action. The OSAP (1990) 
monograph's strengths and conclusions were presented in an 
earlier section, but the concluding emphasis of this work is on 
primary and comprehensive prevention. Mail (1985) lays out a 
rationale and several specific considerations for primary preven- 
tion initiatives in Indian communities, and the Mail and Wright 
(1989) piece says that successful prevention programs will have 



210 



to come from the communities themselves (see also Beauvais 
and LaBoueff, 1985). Marum (1988) describes this community 
generating process with one program in Alaska. 

The last overview piece listed, by Maynard and Twiss (1970), 
was a piece far ahead of its time. From the pilot, model commu- 
nity mental health program at Pine Ridge, South Dakota (1966- 
the 1970s), a vast amount of research was generated on social 
and environmental conditions that were related to mental health, 
drug abuse, and other health and behavioral health conditions. 
This monograph is a summary of much of those studies. It details 
the historical, demographic, economic, social, and cultural condi- 
tions among the Oglala Lakota (Sioux) at Pine Ridge and analyzes 
their significance for behavioral health. A large part of the con- 
cern are the topics of alcohol and drug abuse. Each section of the 
monograph concludes with several suggestions for prevention, 
most of them primary level, as they involve community-wide, 
structural issues. As a monograph on the primary prevention of s 

mental health and drug abuse problems among Indians, it is 
extensive and has no peers. It is unfortunately out of print, but 
might easily be resurrected and reprinted by an appropriate 
Federal or tribal agency. Too often the behavioral health sciences 
lack a memory or do not build on previous endeavors. 

Four pieces listed in figure 9-3 relate to the prevention or 
control of alcohol-related injury. The May (1989b) article is a 
literature review that documents the close tie between alcohol 
and motor vehicle deaths and injuries and outlines a variety of 
suggestions for primary prevention. Similarly, the Smith (1991) 
and IHS (1990) documents outline specific strategies for preven- 
tion of all types of injury and present detailed data to guide and 
support these efforts. Finally, the Macedo (1988) article provides 
a primary prevention perspective on whole communities that 
are "injured" and traumatized by modern forces, particularly 
alcohol abuse, and the paradigm for recovery. 

Fetal Alcohol Syndrome (FAS) has been upheld by many as 
the perfect "spark" or "motivating" topic for primary prevention 
among Indians (May, 1986). Some would say that Indian commu- 
nities and some Indian organizations are leading the way in the 
area of FAS prevention. The three articles on FAS prevention in 



211 






figure 9-3 are all examples of using public education, awareness, 
research, and some diagnostic clinic work to change the primary 
perceptions and behaviors around this issue. It will be interesting 
in the coming years to evaluate the long-term effects of preven- 
tion programs in some communities that participated in the first 
FAS prevention efforts. 

The final primary prevention area is that of alcohol control 
policy and laws. Though some scholars have suggested new 
laws such as legalization of alcohol sales on reservations (Stewart, 
1964; Dozier, 1966; Price, 1975), alcohol policy has rarely been 
used for preventing alcohol-abuse problems. The earlier policy- 
oriented works in figure 9-3 generally address the issue from a 
polarized and simplistic legalization vs. prohibition perspective. 
More recent articles, however, emphasize alcohol policy as a 
complex web of specific provisions that must be tailored or 
matched to the tribal community or border towns involved. 
Si fe All of the above pieces call for primary prevention to be 

made in a comprehensive, community-generated way. Other 
communities throughout the world have done so, and some have 
shown the efficacy of this approach to alcohol issues in a number 
of settings (Yates and Hebblethwaite, 1983; Beauchamp, 1980, 
1990; Institute of Medicine, 1989; Moore and Gerstein, 1981; 
NIAAA, 1990, Chapter 9; Holder and Stoil, 1988; Pittman and 
White, 1991). It seems that the non-Indian literature could hold 
great promise for Indians as well. New community definitions 
and policy need to find their way further into both research on 
Indians and application in Indian communities. 

While the theoretical worth of community-wide policy and 
normative change is immense, implementing such change is 
treacherous and slow. As Gordis (1991) has pointed out, going 
from science to social policy is an "uncertain road," highly influ- 
enced by the types of scientific evidence, cultural and social 
influences, timing, and many other factors. Similar or even 
greater pitfalls have been recorded in many Indian and Alaska 
Native communities (Levy and Kunitz, 1981; Foulks, 1989; Man- 
son, 1989). The nature of the research, the specific research topic, 
the focus, and the method of scientific approach are all vital and 
must be matched with the community. Further, the role of the 



212 



. 






researcher is very important (Beauvais and Trimble, 1992) and 
must be one of sensitivity and cooperation. 

The Alcohol Abuse Problem That 
Comprehensive Prevention Must 
Address 

So much has been written on the problem of alcohol and Ameri- 
can Indians, both popular and scholarly, that it seems almost 
absurd to write any more on the scope of the problem. Unfortu- 
nately, however, much of what is written on the magnitude, 
nature, and characteristics of the problem is too general, not 
critical, and most importantly, not useful for targeted, public 
health prevention programs. Often the literature that is presented 
in alcohol epidemiology is too general. Usual presentations indi- 
cate that the problem is of great magnitude among Indians, it 
is out of control, and solutions are elusive. This "Oh, my gosh, 
ain't it awful" approach is still with us today, and it may lead 
to a "we gotta do something" program. However, more specific 
targeting is needed for: particular alcohol abuse and alcohol- 
related problems; specific high risk groups and abusive peer 
clusters; and particular host, agent, and environmental interven- 
tions. This section will briefly address the scope of these issues. 

It should suffice here to review the latest mortality for the 
various Indian regions and to redirect some common approaches 
and understandings about alcohol and Indians. Therefore, the 
following data presentation will attempt to present mortality 
data in ways in which they are rarely addressed. The purpose 
is to raise the issue of adapting data collection and analysis most 
closely to the overall needs of prevention and social policy for 
broad and comprehensive community public health initiatives. 

Alcohol and other drug abuse take a disproportionate toll 
among most groups of Indians and Alaska Natives in the Western 
United States as compared with both the United States averages 
and the average of the Western States in which Indians live. In 
table 9-1 some relevant and most current mortality data are 
summarized for Indians and Alaska Natives by age and sex- 



213 



specific categories. Without dwelling on the details in the text, 
one can conclude that the national Indian figures indicate higher 
rates of alcohol-related death for both Indian males and females 
in most age categories than found in United States averages. 
This is especially true for alcoholism deaths for both males and 
females in all age groups, but the ratio of Indian to non-Indian 
is highest in the ages before 45 years. Indian males have higher 
rates of death than Indian females for all types of alcohol- 
involved causes and in all age groups. Nevertheless, Indian 
females still have a substantial problem that cannot be ignored by 
prevention and treatment programs. For example, when Indian 
females aged 25 to 34 years are compared with non-Indian 
females for alcohol-involved causes, Indian females die 1.4 to 
12.0 times more frequently, and chronic consumption is the most 
important style of drinking to address for improvement of female 
rates and causes of death. 

ig Indian males also have higher rates of alcohol-involved death 

v 

than other United States males in every age and cause category 

except suicide in the older age groups. In the age group 25-34, 
for example, Indian males die 2.8 times more frequently from 
motor vehicle crashes, 2.7 times more from other accidents, 2.0 
more from suicide, 1.9 times more from homicide, and 6.8 times 
more frequently from alcoholism (alcohol dependence syn- 
drome, alcoholic psychosis, and chronic liver disease and alco- 
holic cirrhosis). While these rates and ratios are insightful, they 
only tell part of the story that is useful for prevention planning. 
In the far right-hand section of table 9-1, the actual number 
of deaths (not rates) from these causes is given for all Indians 
and Alaska Natives. For 1986 through 1988, motor vehicle and 
other accidents, suicide, homicide, and alcoholism caused 4,307 
deaths for males and 1,474 deaths for females for a total of 5,781 
deaths. Using an approximation of alcohol involvement that has 
been gleaned from the Indian and non-Indian alcohol literature 
(see May, 1989a, or May, 1992, for the methodology), the far right 
column provides an estimate of the extent of alcohol-involved 
death. 3 A total of 2,705 male deaths and 951 female deaths are 
estimated to have been alcohol-involved in these three years. Of 
the total of 21,943 Indian and Alaska Native deaths from all 



214 



causes in these years, 17.5% were, therefore, alcohol-involved. 
The differential, however, is very great between Indian males 
and females. Among Indian males, 26.5% of all deaths were 
alcohol-involved, while it was 13.2% for females. This translates 
to a ratio of 2.84 alcohol-involved male deaths to 1 female death, 
which is twice the ratio for non-alcohol-involved death (1.42 to 1). 

In summary of table 9-1, the reader can conclude that: Indian 
males have a greater problem with alcohol-involved death (both 
rates and absolute numbers) than Indian females; the alcohol- 
involved mortality data are worse for both Native males and 
females than for the average United States statistics for most 
every alcohol-involved cause; and the disparity between Indians 
and the United States general population is greatest in the 
younger age groups (see also May, 1989a, 1986). The need, there- 
fore, for preventing alcohol-involved problems is one of a differ- 
ent magnitude, it has very different age and gender implications, 
and it may require slightly different approaches than among the 
general United States population. 

In order to focus prevention efforts on priorities based on 
alcohol-related mortality, programs and funding would have to 
change from what they are today. Below, the data will help 
explicate the priorities as indicated by mortality data. 

From the absolute number of deaths in table 9-1, the highest 
priorities for males of all ages would be alcohol-involved motor 
vehicle accidents (N = 944) and alcoholism (N = 649), with other 
problems ranked less important. For females the priorities would 
be the same, but the disparity between motor vehicle accident 
deaths and alcoholism deaths is not as great (1.25 to 1) as it is 
with males (1.45 to 1). Furthermore, using similar and much 
more detailed analyses for particular age groups or particular 
communities, one could target specific and delimited secondary 
and tertiary prevention much more precisely than it is usually 
done. For example, analysis of actual deaths among Indian males 
under 25 or even 35 years of age would certainly emphasize 
that alcohol-related accidents, suicides, and homicides are of far 
greater concern in number of deaths than are other alcohol- 
related causes. One must also keep in mind that in some Indian 
communities the data would indicate that the priorities should 



215 



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217 



be very different from the national Indian trends shown above. 
Local data analysis and planning are vital for tailoring of preven- 
tion programs. 

To make a further distinction about the pattern of alcohol- 
involved mortality among Indians, table 9-2 is also concerned 
with the different causes of death by rate, number of deaths, 
and similar estimates of alcohol involvement applied to both 
Indians and the United States for 1986-88 and 1987 respectively. 
Considering the rates in the left-hand portion of table 9-2, one 
can see that the age-adjusted rates per 100,000 for United States 
Indians are higher (1.53 to 5.45) than general United States popu- 
lation rates for all five alcohol-involved causes. In fact, the overall 
rate for these five causes of death is 2.79 times that of the United 
States averages. In the middle section of table 9-2, the actual 
number of deaths for these causes is presented. For United States 
Indians the five causes that are frequently alcohol-involved 

I (5 accounted for 4,735 (17.2%) of all Indian deaths for 1986-1988. 

., S When the estimates of actual alcohol involvement from the far 

left column of the table are applied to each cause, the magnitude 
of alcohol involvement is 2,955 deaths, or 17.0% of all Indian 
mortality. This compares with the overall United States figures 
of 7.7% for the same causes and 4.7% estimated as definitely 
alcohol-related. 4 Therefore, the alcohol-involved mortality, as 
measured by rate and as a percentage of all deaths, is currently 
a greater health problem in Indian Country. This is obviously 
consistent with sex-specific data presented in table 9-1. 

The Indian Health Service, Office of Planning Evaluation and 
Legislation, in recent years has attempted to correct for possible 
misidentification of Indian deaths in some areas of the country 
by basing some of its data breakdowns on only 9 of the 12 service 
areas. 5 This may yield a more accurate accounting of the true 
size of the problem as it exists in the more traditional reservation 
areas and isolated Western States. It may also be more representa- 
tive of reservations and Native communities where conditions 
are different from major United States population concentrations, 
and where data are more complete. In the far right of table 9-2, 
these alternate data are presented. In these rates, deaths, and 
percentages based on the nine service areas, it is shown that the 



218 



ratio of alcohol-involved deaths (Indian vs. the United States 
population) is even higher than in the previous comparison 
(3.69), and the estimate of alcohol-involved deaths as a percent 
of total Indian deaths is 19.0% as compared to 4.7% for the overall 
United States population. 

A final distinction from table 9-2 is very important for plan- 
ning and prevention (see Westermeyer, 1976). This is the classifi- 
cation of different types or categories of alcohol-involved death 
(see also IOM, 1990). In the table, deaths are divided according 
to predominantly alcohol- abusive (sporadic alcohol use) and pre- 
dominantly alcohol-specific (chronic alcoholism) deaths. Of the 
four causes of death listed in the upper part of the table, the 
alcohol-abusive causes (accidents, suicide, and homicide), are 
estimated to cause substantially more mortality than the alcohol- 
specific. In the total Indian comparison, the alcohol-abusive 
causes accounted for 2,213 deaths in 1986-1988, and the alcohol- 
specific caused 742 deaths. The percentages are: alcohol-abusive 
= 74.9%; alcohol-specific = 25.1% of all Indian alcohol-involved 
deaths. In the nine-area comparison the data are virtually the 
same: 1,678 (74.3%) for the alcohol-abusive and 580 (25.7%) for 
the alcohol-specific. In the general United States population 
(1987) the percentages are slightly different, 83.9% alcohol-abu- 
sive (N = 83,133) and 16.1% (N = 15,909) alcohol-specific (see 
table 9-2). 

The real significance of the above data to prevention and 
intervention is great. The simple message is this: Alcoholism 
per se is not really the leading or number one health problem 
among Indians. We would be much more accurate in stating that 
alcohol abuse and alcoholism (both sporadic and chronic consumption) 
combine to form the leading health problem among Indians. If health 
and public health professionals and citizens focus solely on 
chronic alcohol consumptive behaviors (Indian anxiety drinkers), 
then up to three-fourths of the problem is ignored. This is also 
true for the overall United States population. Prevention efforts, 
therefore, must embrace all alcoholic and alcohol-abusive behaviors. 
Additionally, special prevention initiatives need to be aimed at 
the specific and particular characteristics of each type of alcohol- 
involved death. One cannot expect to improve all types of alco- 



219 



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hol-involved death with a single type of initiative. Because alco- 
hol-related problems are heterogeneous, multiple measures, 
techniques, and approaches of prevention and treatment are 
necessary to alleviate the extant problems. 

The final table, table 9-3, presents data for the 12 different 
IHS service areas. This table could be considered a prototype 
for specific areas or specific communities to use for planning 
targeted prevention. It documents alcohol-involved causes by 
type, gives an estimate of the alcohol-relatedness of deaths in 
proportion to all deaths, and allows comparison of rates with 
the United States population and the total Indian population. 
Similar tables utilizing age and sex breakdown and local area- 
specific information, comparisons, calculations, analyses, and 
other considerations (e.g., types and locations of alcohol- 
involved crash deaths) could and should also be generated. Such 
local data constructions and analyses would be valuable for tar- 

i fn g etm g specific prevention and intervention measures in a reser- 

vation or local community. Too often prevention efforts have 

: O r not been built on the use of highly focused data, particularly 

l\ locale-based data. 

A summary of the significant information in table 9-3 is 
important. First, the areas vary widely in their experience with 
alcohol-involved mortality. The highest rates of alcohol-involved 
deaths are found in Tucson, Aberdeen, Phoenix, Navajo, and 
Billings, and the lowest in Oklahoma, California, and Nashville. 
Second, the areas have varying rates of the different kinds of 
deaths. For example, some have high rates of both alcohol- 
abusive and alcohol-specific (alcoholism) causes (Aberdeen, 
Albuquerque, Billings, Tucson, and Phoenix). Other areas (Nash- 
ville) have low rates of both alcohol-abusive and alcohol-specific 
deaths. Some other areas, as IHS reports indicate (1990), may be 
affected by under-reporting (California, Oklahoma, and Port- 
land). Finally, others have an unequal mix of alcohol-abusive and 
alcohol-specific deaths (Alaska and Navajo), where the alcohol- 
abusive deaths far exceed the incidence of alcohol-specific. Third, 
the percentage of deaths that are alcohol-involved varies by area, 
from 8.3% to 22.4%. Therefore, variation in alcohol-involved 
behaviors does vary greatly from one reservation or community 



222 



to the next (see May, 1982, 1989a, 1992). Prevention efforts must 
adapt to these variations when planning for, or dealing with, 
alcohol problems from a community-wide, public health per- 
spective. 

Etiological Considerations Vital to Indian 
Prevention 

Several variables have been explored to determine and explain 
the etiology of Indian rates and patterns of alcohol-involved 
behavior and mortality. Standard demographic variables explain 
some alcohol-involved problems in ways that tend to demystify 
Indian behavior and are therefore very useful for prevention. 

First, factors such as the age of the population are very influ- 
ential on alcohol-involved behavior. Because the average >^ 
(median) age of the population of Indians in general, and particu- 
larly among some Western tribes, is below that of both the general 
United States population and the Western States, one would 
expect higher crude death rates from certain behavioral causes 
such as alcohol-involved accidents and violence (May, 1986, 
1989a; May and Smith, 1988; Broudy and May, 1983; May, 1982b). 
Therefore the Indian causes of death reflect those typical of 
youthful populations. Prevention must therefore be geared to 
the high-risk peer clusters of younger Indian people. School- 
based programs only address part of the population and the 
problem, for the bulk of the morbidity, mortality, arrests, and 
problems occur among those who are not in school because or 
age and other reasons. 

Second, most reservation and Western Indians (the bulk of 
the IHS service population) live in rural areas that have a low 
population density. This also elevates the rates of certain causes 
of death such as accidents and violence. Long distances to health 
care and emergency medical system response times in rural areas 
cause up to four times as much death from injuries as from 
similar injuries occurring close to a hospital (Waller, et al., 1964). 
Therefore, prevention in the environment needs to be addressed 
through highway engineering, motor vehicle policy, emergency 
medical care, health education programs appropriate for rural 
Indian lifestyles, and other issues. 



223 



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Third, the cultural, social, and behavioral differences of the 
tribal and Indian sub-populations throughout the United States 
must also be considered, for they cause variance in the death 
patterns of some alcohol-related conditions such as cirrhosis of 
the liver, violence, and other causes of death (see Levy and 
Kunitz, 1974; Broudy and May, 1983; Katz and May, 1980; May, 
1986, 1989a, 1989b; Van Winkle and May, 1986). As was shown 
in Tables 9-1-9-3, American Indian groups have different pat- 
terns of sickness and death for many alcohol-related causes from 
those of non-Indians. There is also aggregate variation between 
tribes and communities due to variations in particular social and 
cultural traits, norms, values, or laws. 

Finally, and most important for this paper, alcohol policy 
directed at Indians has been rather unique. The historical influ- 
ence of alcohol policy directed at Indians has produced particular 
patterns of drinking and mortality that are still evident today 
(Dozier, 1966; May, 1976, 1986, 1992). Knowing and understand- 
ing these factors are important in intervention and prevention 
planning. Etiological knowledge is very important and should 
be pursued as part of prevention activity. Gaining knowledge 
of cause, particularly as manifested in local Indian communities, 
is truly a key in picking and /or designing the proper prevention 
approaches. Without such knowledge, or a pursuit of such 
knowledge, prevention efforts or programs may not be effective. 
Furthermore, it is my experience that the pursuit of scientific 
notions of pattern, cause, and knowledge gain is very stimulating 
to prevention activities. 

The above discussion of the problem of alcohol abuse among 
Indians is intended as a limited overview of mortality only. 
It is, however, one tailored to the needs of broadly focused 
prevention. Mortality provides excellent data for indicating prob- 
lems from which to start prevention, for it is one of the few 
alcohol-involved outcomes that produce unduplicated counts. 6 
It is also a type of data which is quite complete and less compli- 
cated by agency or local peculiarities. Arrests, morbidity, and 
health and social service program data all have the problem of 
aggregating multiple episodes or visits for a limited number 
of individuals. The data generated by these individuals might 



226 



appear to be a much larger number and therefore a larger, less 
specific, and different problem than that which needs to be 
addressed. 

Discussion: The Orientation and 
Content of a Community Alcohol 
Abuse Prevention Program 

In closing this paper a summary discussion is in order. What 
should be done for the prevention of alcohol abuse in an Indian 
community? Mohatt and Blue (1982) relate the following anec- 
dote: 

Peter Kelly, Chief of the Sabaskong Reserve in northwestern 
Ontario, has concluded that everyone studies the Indian to find 
out what is wrong, but that nobody does anything about it. 

The literature summarized in this paper shows that programs 
are attempting to do something about it. The goal of the future 
should be to undertake comprehensive, community- wide efforts 
for alcohol abuse prevention. 

A Public Health Perspective 

A comprehensive community approach to prevention must focus 
on a public health perspective. In a public health approach the goal 
is to apply comprehensive strategies and programs that reduce 
the rates of affliction and early death among total groups and 
aggregates of individuals (Beauchamp, 1980). Often the target 
would be all people on a particular reservation and in border 
towns nearby. The focus therefore is on communities and particu- 
lar geographic areas and not on individuals. Further, no one type 
of alcohol abuse prevention should be championed, but various 
programs and approaches should fit together in a mutually sup- 
portive and beneficial manner (May, 1992). This is not unlike 
the analogy of a patchwork quilt. Therefore, primary, secondary, 
and tertiary levels of prevention dealing with a variety of the 
alcohol-involved behaviors would all be utilized and coordinated 
(see Manson, Tatum, and Dinges, 1982; Bloom, 1981; May, 1992). 
All of the various programs described in this paper, then, are 



227 



X i 



not at all mutually exclusive, but can be mutually supportive 
if orchestrated by a comprehensive community-wide plan and 
approach. Once the problems and priorities of a community are 
set from research, data analysis, and local wisdom, the proper 
set of programs and approaches can be established drawing 
heavily on the literature presented here. A community will want/ 
need to have some prevention programs of all levels (primary, 
secondary, and tertiary) in place, along with health and drug 
abuse treatment programs. Communities will also need to plan 
for monitoring or evaluation the outcome of their efforts. 

In the past there have been studies on how some Indian 
communities have been destroyed by adverse forms of modern- 
ization and change, and how alcoholism has served as a major 
co-factor in the negative process (Maynard and Twiss; 1970; 
Shkilnyk, 1985). On the other hand, Alkali Lake and other experi- 
ences raise the hope for, and expectations of, the healing process 
(Ward, 1984; Fox, et al., 1984; Macedo, 1988). Comprehensive 
alcohol abuse prevention programs can be a major vehicle in the 

O I process. Below is a summary of the general considerations that 

the literature cites as important in prevention among Indian 

;3 communities. 

Cultural and Local Community 
Relevance 

Prevention programs that are carried out in Indian country must 
be designed in a way that allows the content of the program to 
be shaped and molded to fit the tribal culture. Further, prevention 
programs must help the tribe in their efforts of empowerment 
(Beauvais and LaBoueff, 1985). Prevention programs can be initi- 
ated by outside "experts" working with tribal leaders, but the 
continuation and entrenchment of the activities must be carried 
on by individuals in the local community (OSAP, 1990). This 
does not mean that prevention plans cannot be designed for one 
tribe and then transferred to others. It means that programs 
should be made relevant to local norms, values, and conditions 
through particular, culturally sensitive adaptations (May and 
Hymbaugh, 1989). Many adjustments made for a particular tribe 



228 



or community can be very minor, and, while cultural specificity 
is important, it need not be a total obstacle either theoretically 
or politically. 

Policy Considerations 

Alcohol and other drug abuse policy initiatives are approaches 
to prevention that have been infrequently addressed or tried in 
the past (May and Smith, 1988). Alcohol policies of prescription 
are extremely rare, for the norm on most reservations is self- 
imposed proscription (May, 1977). Most tribal alcohol statutes 
are not very specific in their provisions for the control and 
enforcement of alcohol or prescription of behavior once a person 
has been drinking. Further, the informal norms that surround 
drinking behavior in many Indian peer groups and communities 
are not serving the best interests of either individuals or the 
masses. Normative expectations, therefore, need to be considered 
in prevention efforts. Specific and detailed policy designed to 
shape alcohol-related behavior has rarely been undertaken for 
a variety of reasons (May, 1986, 1992). Because most reservations 
are under prohibition, alcohol prevention efforts such as dram 
shop laws, bartender training, strict license provisions, tribal 
mandates, and situational drinking norms have seldom or never 
been used or researched for Indians on reservations or in other 
rural areas (May, 1976). Policy measures will very strongly sup- 
port other prevention initiatives such as those that address the 
socio-cultural values of youths and other targeted drinkers (New- 
comb and Bentler, 1989). 

Programs to prevent alcohol and drug abuse among Indians 
must address both sporadic and binge use as well as chronic 
consumption (May, 1989a). As the data in this paper showed, 
Indians suffer twice as many deaths from alcohol-related acci- 
dents, suicide, and homicide as they do from indicators of chronic 
consumption such as cirrhosis of the liver, alcohol dependence 
syndrome, and alcoholic psychosis (OTA, 1986; IHS, 1991b). But 
age-adjusted rates of death for both chronic and sporadic abusive 
causes are above national average rates. This is particularly true 
on some very high-risk reservations in the Western United States. 



229 



. 



Therefore, the actual programs must be tailored to the conditions 
of the particular community. 

Alcohol Issues for Females 

Among neglected and growing problems that must be addressed 
by prevention programs in the future is that of female alcohol 
and drug use. Prevalence of female drinking is growing rapidly 
in some tribes, and has been relatively high in others for some 
time (May and Smith, 1988; May, 1989a; Whittaker, 1962; 1982). 
Consequently, the cirrhosis death rate of Indian females is now 
about 50% that of Indian males. But the danger is that female 
alcohol problems will remain unrecognized or unaddressed, as in 
the past, with both Indians and other groups. Female alcoholism, 
particularly among those of childbearing age, has very grave 
implications for the future of major Indian groups (Dorris, 1989). 



The Drunken Indian Stereotype and 
Prevention 

r= m 

Health education and prevention programs carried out in Indian 

country should address issues that are currently shrouded in 
the myth of the "Drunken Indian Stereotype." Many components 
of the myth are inaccurate (Westermeyer, 1974: Leland, 1976), 
and therefore may impede productive prevention planning and 
efforts (May and Smith, 1988; May, 1992). Prevention efforts 
cannot embrace, or fail to deal with, the scientifically inaccurate 
idea that Indians are so different biologically, culturally, or in 
other ways that they cannot benefit from the experience of other 
human beings. This, however, is a great challenge, for in some 
tribes like the Navajo, a majority (63%) of the people believe that 
Indians have a special physiological weakness to the effects of 
alcohol (May and Smith, 1988). A major deficit in the rate of 
alcohol metabolism or any other particular physiological predis- 
position to alcohol abuse has never been documented in the 
scientific literature to date (see Schaefer, 1981; Reed, 1985; or 
May, 1989a, for reviews). 

Dealing with such misconceptions in a prevention program 
facilitates the transfer of many ideas and approaches for preven- 



230 



tion. Once misconceptions and myth are examined with facts, 
many prevention strategies from mainstream and non-Indian 
populations can be transferred to Indian populations with only 
minor modification. As indicated in the literature review, many 
authors have concluded that social learning theory is quite gener- 
ally applicable to solving problems of alcohol abuse among 
American Indian youths and adults (Bach and Bornstein, 1981; 
Winfree, et al., 1989; Sellers and Winfree, 1990). Knowledge and 
education-based programs that focus on correcting misconcep- 
tions and fostering new thinking about solutions are promising 
and may even be healing experiences (Beauvais and LaBoueff, 
1985). 

Indians generally know the negative consequences of alcohol 
quite well (May and Smith, 1988). But prevention efforts may 
have to work to reduce fatalism and to impart other, policy- 
relevant and action-specific information to initiate and entrench 
solutions. Prevention aimed at the presentation of knowledge 
on the adverse consequences of alcohol abuse alone will be of 



might be taken in the future (OSAP, 1990). Prevention programs 
should begin with opinion and knowledge surveys of Indian 
adults in the target communities to assess the current conditions 
and traits. Then more relevant education and community-based 
programs will be forthcoming. 

Strengthening Existing Institutions in 
Communities 

A prevention program among Indians has to include plans for 
involving and strengthening the community and family. Indian 
families that are strong and well integrated produce children 
with better indicators of adjustment, and usually fewer indicators 
of deviance (Jensen, et al., 1977). Conversely, disorganized, multi- 
problem families have higher alcohol utilization and more health 
and deviance problems (Spivey, 1977; Lujan, et al., 1989). Com- 
munity-wide programs can and must also serve to strengthen 
or mobilize a community in a number of ways. 






limited value. Prevention efforts designed to initiate specific, 
programmatic policy and community solutions are the thrust that 






231 



Therefore, a complete prevention program in an Indian com- 
munity must be built on the particular epidemiology of the area 
and be designed with local culture, norms, values, beliefs, and 
conditions in mind. Programs must aspire to research, under- 
stand, and decrease morbidity and mortality. Implementing pro- 
grams of health education, policy initiatives, increasing commu- 
nity awareness of solutions, and initiatives designed to assist in 
norm clarification, definition, and prescription and proscription 
of behavior hold promise for prevention. Further, such efforts 
must be coordinated with a variety of health care and social 
service agencies, treatment programs, and criminal justice agen- 
cies. 

Community mobilization, designed from within the commu- 
nity, seems to be the promise of the future in the prevention of 
alcohol and other drug abuse among Indians (May, Miller, and 
?£ Wallerstein, in press). In spite of the extremely unfortunate treat- 

& {g ment of Indians in North America in the past, most Indian com- 

*. ; "r ' C munities have many cultural traditions, values, institutions, and 

structures that can add to or carry forward community-wide 
prevention initiatives. The research ideas and prevention tech- 
niques and proposals presented here can be meshed with tribal 
traditions to minimize the problems of alcohol abuse in the 
future. 



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End Notes 

1. Primary prevention is the promotion of health and elimina- 
tion of alcohol abuse and its consequences through commu- 
nity-wide efforts, e.g., improving knowledge, the environ- 
ment, and the social structure, norms, and values. Secondary 
prevention utilizes measures available to individuals and 
populations for early detection with high risk persons and 
groups (e.g., youth) and prompt and effective intervention to 
correct or minimize alcohol abuse in the earliest years of onset. 
Tertiary prevention consists of measures taken to reduce 
existing impairments and disabilities and minimize suffering 
caused by severe alcohol abuse or alcohol dependence 
(adapted from Last, 1983). 

2. The reader who is even more interested in mental health 
issues, either independently or as they relate to drug abuse, 
should definitely consult Manson (1982) and OSAP (1990). 

3. Actually this estimate may be conservative for Indians, for 
autopsy studies of motor accident victims that are in progress 
in New Mexico, by May, Bergdahl, Guerin, and others (See 
Bergdahl, 1991, and Guerin, 1991), show 70 to 85% alcohol 
involvement in Indian crashes. Further, other accidents might 
be 40% or more alcohol-involved in some areas. 

4. Actually these estimates of alcohol involvement may overesti- 
mate U.S. alcohol-related deaths. For example, U.S. literature 
on suicide and homicide seldom indicates more than 50% 
alcohol-involvement for suicide or more than 70% for homi- 
cide. Further, motor vehicle accidents are usually reported as 
50% alcohol-related in many states. Nevertheless, for consis- 
tency and to account for possible under-recording in various 
communities in the nation, these same alcohol-relatedness 
factors were used for both U.S. and U.S. Indian calculations. 



242 



5. These nine areas are: Aberdeen, Alaska, Albuquerque, 
Bemidji, Billings, Nashville, Navajo, Phoenix, and Tucson. 
Excluded are: California, Oklahoma, and Portland areas. 

6. Mortality data for some causes of death and for states, cities 
and sub-populations of the United States might be less reliable 
than those produced for American Indians in western states. 
Factors such as incomplete or inaccurate classification of cause 
of death, missing data on alcohol relatedness, variation in 
coding by social class and other issues must be kept in mind 
and assessed when using mortality data from any group or 
community. Death data from the vital statistics should be 
cross-referenced with autopsy data, police data, state records 
and other sources when possible. 






> 






243 



o 



K © 









10 

Native American 

Community Alcohol 

Prevention Research 

Pamela Jumper Thurman 



N 

Introduction 

Concern over the issue of American Indian alcohol and other 
drug use has stimulated a major interest on the part of researchers 
to identify successful and sensitive methods of prevention and 
treatment for this population. As a generally underserved and 
understudied population, American Indian communities are cer- 
tainly in need of appropriate and responsive research models, 
measurement tools, and reliable data on the nature and extent 
of drug abuse. This paper will present the demographics of 
American Indians and Alaska Natives, briefly discuss the rather 
significant history that has resulted in the current Tribal and 
Native structures, present some information on the incidence 
and prevalence of drug abuse within this population, and discuss 
how these factors relate to the current state of collaboration 
between Native communities and researchers. 

May (in this monograph) has provided a thorough demo- 
graphic description of the American Indian population in the 
United States and makes it apparent that American Indians are 
a very diverse group of people. Frequently the majority culture 
tends to view American Indians and Alaska Natives as a homoge- 
neous group — as "Indians" whose customs, beliefs, and tradi- 



245 



tions are very similar. However, this is most certainly not the 
case. American Indians and Alaska Natives are a highly diversi- 
fied group of people with not only individual and family differ- 
ences, but tribal and cultural differences that vary greatly from 
location to location, often even within the same geographic locali- 
ties. For example, differences exist in appearance, clothing, cus- 
toms and ceremonies, traditional practices, family roles, child 
rearing practices, beliefs, and attitudes. Each tribe, band, or 
Native village maintains a unique perception of the world both 
inside and outside of their particular area. Even within the same 
tribe, differences exist. Some Indians or Natives are very tradi- 
tional in their beliefs, maintaining tribal languages, ceremonies 
and customs, while others may be more contemporary, holding 
to some Indian traditions while maintaining a successful orienta- 
tion to non-Indian society as well. 

One striking similarity shared by all American Indians and 
Alaska Natives is a long history of Federal or governmental 
control over Tribal /Native issues as well as control over many 
individual decisions. There have been major Federal attempts 
for removal of Indians and Natives from homelands, sterilization 
of women of child-bearing age, and relocation programs. Assimi- 
lation attempts have included legal efforts to stop various cere- 
monies and dances, restrictions on speaking Native languages, 
and again, relocation programs. Pamela Kalar (1992) states that 
' 'cultural insensitivity, voracious greed, paternalism and the bit- 
ter fruits of inept lawmaking have compounded the inequities 
suffered by Native peoples on and off the reservation. ,, Often it 
is forgotten or overlooked that these "First Americans" were not 
given voting citizenship until 1924 in most States and not until 
1946 for Arizona and New Mexico. \ 

Even identification as an Indian can follow many different 
guidelines. There is no single definition of an Indian. Some tribes 
define by blood quantum, and others may use family or clan 
identification. There are also people who identify by level of 
acculturation or even self-identification as an American Indian. 
In fact, some institutions, such as schools, universities, or the 
United States Census (1990), accept self-identification as the fac- 
tor that determines whether or not a person is American Indian 



246 



or Alaska Native. In some cases, even people who may be Indian 
by blood quantum may not be accepted by others in the tribe 
as "Indian." This ambiguity of definition affects legal issues and 
research agendas as well as individual situations. 

Recent congressional actions have returned some power to 
Indian and Native Nations through legislation such as the Self 
Determination Act, Indian Education Act, and the Indian Child 
Welfare Act. Such mandates have begun to empower Indian 
people to the extent that many American Indians and Alaska 
Natives have involved themselves politically in major decision- 
making issues. There is, once again, an American Indian in the 
Senate, and many powerful political American Indian and Alaska 
Native role models. 

However, it is significant to note that, although there have 
been political successes, sadly, there are still few economic suc- 
cesses. Many Native families still experience poor nutrition, live 
in substandard housing, and lack the resources necessary to 
provide their children with choices for positive opportunities. 

Another encounter shared by most Native groups is the 
boarding school experience. From the late 1800's to the 1960's, 
church-affiliated boarding schools, in their attempts to success- 
fully assimilate Indian people, literally terrorized many Native 
children. They were punished, often severely, for speaking their 
Native language, were humiliated in front of their peers, and 
received extreme hair cuts in an effort to conform to "White 
society." Although the Bureau of Indian Affairs still maintains 
several boarding schools, today's efforts are much improved 
from those earlier endeavors and, in fact, include cultural curricu- 
lum and employ many Native teachers and staff. 

These historical events are discussed here only because they 
influence the current political and personal environment of 
American Indians and Alaska Natives; they are factors which 
must be considered when conducting research in these communi- 
ties. If there is an aura of distrust, there are long-standing and 
solid historical reasons for those feelings. 

American Indians and Alaska Natives still suffer from preju- 
dice and lack of access to many of society's benefits. They have 
been targeted as having high rates of school dropout and poor 



247 



economic prospects. All of these factors are also believed to place 
them at high risk for drug abuse. It has also been speculated 
that when Natives live in rural towns and /or reservations, drug 
abuse problems may be even worse because there are so few 
effective local resources for either treatment or prevention. 









American Indian Substance Use 

Alcoholic beverages or spirits were relatively unknown to most 
American Indian tribes previous to European contact. The early 
19th century brought numerous White traders into Indian terri- 
tory. Alcohol may have been given to the Indians initially as a 
gesture of friendship. The Indians developed an attraction to 
these new "spirits" and, consequently, drunken behavior began 
to appear. Loss of control and an inclination to drink until the 
supply was exhausted were major characteristics of the Indians' 
initial drunken reactions to alcohol (Dozier, 1966). Because of 
the novelty of alcoholic beverages, tribes really had no estab- 
lished social patterns or codes for regulation of alcohol use. 
Additionally, there was an uncertainty about how to react to 
drunken behavior and whether or not to condone it, tolerate it, 
or ignore it. 

In an effort to present some of the major theories behind 
drug abuse among American Indians, it is probably necessary 
to address the literature's references to the vision or dream quest 
and its similarity to alcohol inebriation (Carpenter, 1959), if only 
to acknowledge that some drugs are still used today for ceremo- 
nial purposes. Carpenter believed that Natives who adhered to 
the traditional beliefs often sought the state of inebriation because 
they equated it with the spiritual experience of the "vision quest." 
It is very difficult today, however, in any manner, to equate 
addiction or alcoholism /drug abuse with any religious or spiri- 
tual experience. In fact, contemporary users of traditional drugs 
such as peyote, tobacco, and mushrooms in ceremonies are radi- 
cally opposed to illicit or recreational drug use. Natives who 
use drugs for religious purposes consider their use to be very 
ritualized and extremely controlled. Alcohol is disallowed at 
these prayer or healing ceremonies. For example, if it is discov- 



248 



ered that a plant, such as peyote, has been used incorrectly, rather 
than maintain that plant for future ceremonies, it is destroyed by 
the spiritual leader. 

Incidence and Prevalence of 
Alcoholism 

For those planning research endeavors in American Indian or 
Alaska Native communities, it may be helpful to recognize some 
of the challenges that will be encountered. Not only are there 
many tribal differences, but there are differences in the incidence 
and prevalence of drug abuse in Indian communities as well. 

Given the tribal and village differences, it is not surprising 
that alcohol and drug use among Natives vary tremendously ^ 

from one group to the next (May, 1982). May (1986) cites some Q 

tribes as having fewer drinking adults (30%) than the U.S. popu- 
lation (67%) while other tribal groups have more (69%-80%). 
For instance, in 1988, Juanita Learned of the Cheyenne Arapaho 
Tribes in Oklahoma (1990) indicated that there were 33.9 deaths 






(per 100,000 population) among American Indians in that region 
caused by alcohol dependence syndrome, alcoholic psychoses, 
and chronic liver disease and cirrhosis. This rate is 5.4 times 
greater than that of the Americans of all races dying from these 
same causes in 1988. Some even believe that these numbers are 
understated due to deaths occurring for reasons such as alcohol 
related injury, suicide or homicide. Certainly these data support 
the need for successful collaboration between the Native groups 
and the research community to clarify the true extent of the 
problem and design methodologies that would supply the valu- 
able treatment and prevention information to significantly 
decrease these use statistics. 

When considering the youthfulness of the American Indian 
and Alaska Native population, it seems necessary to include 
prevalence information specific to this group. It has been estab- 
lished that Indian youth use most every type of drug with greater 
frequency than non-Indian youth and that the age of first involve- 
ment with alcohol is younger for Indian children. The rates of 
drug use and involvement can even be two to three times higher 



249 



for American Indian youth than for Anglo youth (Beauvais, 
1992). 

Other research by Swaim (1991) in the area of risk factors 
for drug-abusing Indian youth has cited low family caring, poor 
school adjustment, weak family sanctions against drugs, positive 
attitudes toward alcohol use, and risk of school dropout. Litera- 
ture is also consistent in the premise that drug abuse behavior 
is to a large extent influenced by cultural values and norms. Yet 
another risk factor that accounts for high use rates among Indian 
youth is a lack of educational and employment opportunity. 
When Indian youth begin to reach adulthood, they find few 
chances of securing decent jobs, limited educational opportuni- 
ties, and scant resources for improving this situation. This lack 
of opportunity is difficult for these young people and may also 

t . be a contributing factor in the potential of alcohol and /or drug 

use. In these situations, getting high could certainly become more 

JS j§ ^ attractive than reality. 



.._• ... 



Research Challenges 

These factors reflect only a portion of the challenges that many 
Native groups are experiencing. Often it may be preferable to 
Native entities to be ignored completely rather than continue to 
read about the negative aspects of being Native. It isn't difficult 
to realize why the presence of researchers within a Native com- 
munity can be regarded with mistrust and sometimes even hostil- 
ity when the resultant article presents problems which then even- 
tually become associated with "all Indians/ 7 The problem areas 
and negative aspects receive the most attention while the major- 
ity of healthy successful Native families and what makes them 
that way are overlooked. It is imperative that all researchers: 

(1) view Natives as people of social equality, who are invested 
in developing their own problem statements and solutions; 

(2) respect Native culture and tradition; (3) acknowledge and 
collaborate with the Native Councils and persons of authority; 
(4) accept the concept of Tribal and Native diversity; (5) avoid 
generalizing findings in one Native community to all Native 
communities; and (6) contribute something of value to the Tribal 
quality of life. 



250 






Community/Researcher 
Collaboration 

In reviewing an article by Joe Trimble (1977), it was realized 
how little the issues have really changed in 15 years. He indicated 
that scientists from a variety of disciplines have "poked their 
noses, notebooks, cameras, and videotape equipment in Indian 
communities. ,, He lists as some of the major research problems: 
(1) little, if any, community or tribal participation in anything 
other than the data collection procedures, (2) findings that con- 
tribute to controversy, (3) the suspicion with which many Native 
communities view research, (4) intrusion into the culture, (5) lack 
of tribal policies regarding research endeavors, (6) results that 
contribute little to provide a basis for program development or 
problem solving, and (7) findings that are viewed in non-native 
theoretical frameworks. Trimble provided an excellent and thor- 
ough discussion of the many barriers that exist in building posi- 
tive collaborative relationships between researchers and tribal 
or Native entities. 

It is often very discouraging for tribes when one considers 
that much of what has been published about American Indians 
and Alaska Natives has proven to be more of a liability than an 
advantage and may even result in controversy. Since the design 
of most research strategies for American Indians and Alaska 
Natives usually explores problem areas, it is necessary to proceed 
with care; otherwise, it is possible to maintain negative stereo- 
types and to assume that Natives, as a whole, are consumed 
with nothing but problems. In reality, there are many healthy, 
successful Native families that are making a positive impact in 
their communities. Research findings could be presented in a 
way that they would contribute something back to the tribal 
community or village by including information that would 
(1) alter negative perceptions, (2) convey some message of hope, 
(3) raise awareness of other researchers, (4) build Native support, 
(5) increase positive images of Native people, and (6) assist in the 
development of programs that promote increased opportunities 
and self-sufficiency. 



251 



Characteristics of a Successful 
Research Collaboration 

The Tri-ethnic Center for Prevention Research at Colorado State 
University recently implemented a pilot prevention project in a 
rural town in the United States. There is a significant American 
Indian population in this town and many students, Indian and 
non-Indian, reported high alcohol, marijuana, and other drug 
use. Because of this usage level and the school 7 s willingness to 
participate, it was decided to initiate a pilot project that was 
community generated and culturally specific to the tribe living 
in that area. 

Local data were collected regarding drug- and alcohol- 
related statistics. Lengthy discussion groups were held with 
school staff, parents, students, and tribal people to formulate a 
problem statement, define the issues to be explored, and develop 
strategies that might be successful for this specific group of stu- 
dents. The research staff participated strongly, but respectfully, 
in these discussions in an effort to maintain scientific integrity 
in the methodology and implementation of the project. It was 
determined that there was insufficient community cohesiveness 
to attack this problem, little parent involvement to encourage 
academic success of the children, and few activities for this some- 
what isolated town to offer the students. It was also determined 
that the school and the Tri-ethnic Center could collaborate with 
a high potential for success. At that point, the group formulated 
the types of activities and strategies that were appropriate for 
their community. This type of involvement also seemed to pro- 
mote community investment. 

Measurement processes and data collection procedures were 
developed with great care and time lines were established. Only 
a very small amount of money ($10,000) was allocated to this 
project in order to allow replication for similar areas with limited 
resources. The money was used for printing costs, materials, 
and supplies. A person from a nearby community with similar 
demographics was trained by center staff and used as the primary 
data collector because she could speak the Native language, was 
familiar with the type of community and the people in it, though 



252 



■ 






not personally acquainted with the target population, and she 
was Native and therefore knew the cultural norms. 

The principal community /family event was a culturally 
focused dinner, a local Native activity involving traditional 
foods, games, storytelling, Native and non-Native dance, and 
music. The event also served as yet another primary data collec- 
tion point. The community response was overwhelming! It was 
the largest turnout ever recorded in the history of the school. 
Parents had an opportunity to meet teachers on an informal basis, 
and all participants received prevention tips and information 
materials. Both cultures met and interacted in a successful event 
that could never have occurred without knowledge and respect 
of the culture and involvement of Native and community resi- 
dents in the identification of the problem and potential solutions. 
The Tri-ethnic Center obtained valuable data on prevention in 
rural Native communities. 

Some of the major research challenges in this project involved 
finding the people in the school system who were willing to 
take on additional activity planning without pay compensation. 
Teachers and counselors usually have a full work day, and to 
add additional tasks is difficult. Volunteer help to implement 
and supervise the activities was difficult to obtain during the 
first year; but, following the success of the major community 
event, many parents and teachers volunteered for year two. The 
researchers tried to adhere to the guidelines discussed earlier in 
this article: continuing efforts were made by research staff to 
make certain that something would be contributed back to the 
community; in presenting the data, negative perceptions were 
not perpetuated by over- generalizing, by presenting only the 
problem areas, or by using stereotypes. Finally, the outcome 
resulted in the development of a program that the local popula- 
tion could be sure would promote increased opportunities and 
self-sufficiency. 

Mechanisms to Improve Access 
and Trust 

Given the interest in American Indian and Alaska Native cultures 
as well as in other minorities, one would think that there would 



253 



<D 



be a fair amount of literature available on methods of conducting 
relevant studies in these communities. Yet, there is very little 
direction on the structural components of successful research 
endeavors. Certainly the prevalence and incidence of alcohol 
and other drug use in understudied populations has received 
attention, and the need for additional literature is also recog- 
nized. However, there continues to be a need for well trained 
ethnic /racial researchers with knowledge of working with spe- 
cial populations to serve as principal investigators, advisors, 
reviewers, advocates, and mentors. 

Major institutions have already recognized this need and 
several commendable programs have been established. As one 
example, in 1986, the National Institute on Drug Abuse intro- 
duced the Minority Research Development Seminar Series, 
whose primary mission was to provide training opportunities 
to ethnic minorities. The program has had considerable impact 
on the growing number of competent ethnic /racial researchers. 
Certainly, programs such as this one should be continued and 
enhanced in an effort to expand the pool of accomplished 
scholars. 

Major funding institutions can continue to enhance research 
with special populations through the development of new T meth- 
odologies that are culturally relevant for special populations. For 
American Indians and Alaska Natives, such considerations might 
be given to (1) communication barriers, such as language, 
(2) cultural norms and standards, and (3) political circumstances 
and perceptions. The recognition of and respect for Tribal or 
Native Council resolutions is important when research is con- 
ducted on reservation lands. In fact, funding sources could con- 
sider making this a requirement for grant applicants planning 
research on reservation lands. An appointed advocate for the 
tribe or village could act on a consulting basis to the researcher 
in an effort to ensure cultural sensitivity. The use of tribal advo- 
cates or special tribal or village advisors might even be included 
on the review committees to ensure that awareness of and respect 
for cultural norms are appropriately addressed. 

The tribes or villages to be researched have special challenges 
that must be addressed. There is concern that yet another intruder 



254 



s 



is coming into the circle to tell them what's wrong with their 
tribe or village. Often appropriate consent is not obtained and 
sensitive information is not strictly guarded. Frequently, tribal 
members are used to collect sensitive data. One pitfall is that 
villages and reservation areas are small — the Native community, 
in fact, is quite small — and such information can involve relatives 
or friends. This lack of confidentiality can result in refusal to 
participate in research endeavors. 

The researcher also faces special challenges. As Trimble 
(1977) pointed out, the researcher must engage in more personal 
involvement when researching American Indian or Alaska 
Native villages. The people want to know who the researcher 
is and why he or she is there. There have been many intruders 
on Native lands and, initially, the researcher will be just one 
more. The Natives may invite the researcher to dinner or to tea 
in an effort to learn more about the researcher. A refusal on the 
part of the researcher may even result in closed doors to the 
research endeavor. One must also know the culture; ensure 
appropriate and sensitive data collection; develop valid instru- 
ments; acknowledge, respect, and collaborate with the ongoing 
changing governmental situations; honor customs; and commu- 
nicate effectively while producing rigorous science. In view of 
these challenges, it is necessary to develop appropriate initiatives 
that will temper good science with consideration of cultural 
differences. Researchers often arrive in Native communities, stay 
only for brief amounts of time, and fail to gain the full extent 
of information that might be needed to appropriately formulate 
the results. Even then, they may perceive their findings through 
a non-Native framework which can make the Natives appear 
dysfunctional, abnormal, or deviant. Often researchers are not 
trained to really listen to tribal or village concerns. They can be 
quite capable of communicating their own concerns for research 
purposes, yet fail to address the concerns of the population they 
are studying. It is imperative that researchers leave these commu- 
nities something of value that can be utilized for program devel- 
opment. "Something of value" can be the practical recommenda- 
tions resulting from the research endeavor. Finally, results for 
one tribe must not be generalized to all other Indian or Native 



255 



groups. Tribes and villages are extremely diverse; this fact must 
be recognized by anyone conducting research with special popu- 
lations. 

Specific Alcohol Prevention 
Intervention Issues 

It is helpful to researchers to include a brief history of the Indian 
Health Service Alcoholism and Substance Abuse Program, since 
these entities have a multitude of data and are prominent in 
most Native areas. At some point, the researcher will probably 
find it necessary to communicate with the Indian Health Service 
to gather background data. 

This group has been the primary funding source for alcohol 
intervention in most tribal areas. In 1986, the Anti-Drug Abuse 
Act was passed by Congress with a subtitle that focused on 
American Indians and Alaska Natives. This appropriation pro- 
vided funds for tribal leaders and staff training on alcohol and 
substance abuser and mandated youth services in both commu- 
nity-based rehabilitation and aftercare, and adolescent regional 
treatment centers. It called for the development of Tribal Action 
Plans to address drug abuse. These events were important as 
they led to a recognition among tribes and villages that drug 
abuse was a problem to be dealt with and that there would be 
Federal support to assist in the challenge. This recognition had 
a great impact on the awareness level of tribal officials and 
focused efforts toward improved services and quality treatment. 



Research Needs 

It is essential, however, to recognize that treatment and preven- 
tion programs for American Indians and Alaska Natives must 
be improved. Additional research is needed on these programs. 
Most treatment programs are usually based on the 12-step con- 
cept, adhere strictly to a medical model, and are addiction 
focused. This creates a somewhat narrow approach to which 
many youth and women do not respond successfully in treat- 
ment. Though some improvements may have occurred, other 



256 



methods and approaches must be explored in order to effectively 
address the problem of drug abuse. Such research could add 
valuable information to meet the challenge of quality treatment 
for Indian and Native youth. Most of these programs are severely 
underfunded and yet could successfully collaborate with 
researchers to improve treatment /prevention services and con- 
tribute significantly to the alcohol and other drug use literature 
related to American Indians and Alaska Natives. Such efforts 
would provide another source for additional funding and begin 
a potentially successful collaboration that would benefit all 
concerned. 

In conclusion, there will always be similarities within cultures 
as well as differences. Many problems are shared by all cul- 
tures — school dropout, alcohol-related deaths, suicides, homi- 
cides, poverty and lack of opportunity, and drug abuse. While 
many cultures share these challenges, they are of particular con- 
cern when they affect youth. American Indian and .Alaska Native 
youth deserve to be a top research priority. We are losing far 
too many of these children to alcohol-related causes. It is impera- 
tive that we make every endeavor to focus our finest research 
efforts on this special population. Although its disheartening 
that we still face the same research problems that we did in 197", 
we have made significant gains — more minorities are trained 
and practicing in research, Federal programs are focused on 
special populations, and researchers such as Oetting, Beauvais, 
Trimble, May, and Manson are serving as excellent mentors. We 
have challenges to meet, and we continue to gain the resources 
to meet them. 



References 



Bureau of the Census. United States Census of Population. Washington Govern- 
ment Printing Office, 1990. 

Bureau of the Census. United States Census of Population. Washington Govern- 
ment Printing Office, 1980. 

Beauvais, F. Trends in Indian adolescent drug and alcohol use. American Indian 
and Alaska Native and Mental Health Research Journal, 5, Issue 1, 1992. 

Beauvais F.; Oetting, E.R.; Wolf, W.; and Edwards, R.W. American Indian youth 
and drugs: 1975-1987, A continuing problem. American Journal of Public 
Health, 79(5): 634-636, 1989. 



257 



Carpenter, E.S. Alcohol in the Iroquois Dream Quest. American Journal of Psychi- 
atry, 116:148-151, 1959. 

Dozier, E.P. Problem drinking among American Indians. Quarterly Journal of 
Studies of Alcohol 27:72-87, 1966. 

Kalar, P. Issues to Consider. The American Indian and the Media. The National 
Conference of Christians and Jews, 1992. 

Learned, J. Personal Communication, 1990. 

May, P.A. Substance abuse and American Indians: Prevalence and susceptibil- 
ity. International Journal of the Addictions, 17:1185-1209, 1982. 

May, P.A. Alcohol and drug misuse prevention programs for American Indians: 
Needs and opportunities. Journal of Studies on Alcohol, 47:187-195, 1986. 

May, P.A., and Dizmang, L.H. Suicide and the American Indian. Psychiatry 
Annals, 11:22-28, 1974. 

Oetting, E.R., and Beauvais, F. A typology of adolescent drug use: A practical 
classification system for describing drug use patterns. Academic Psychology 
Bulletin, 5: 55-69, 1983. 

Oetting, E.R., and Beauvais, F. Peer cluster theory, socialization characteristics 
and adolescent drug use: A path analysis. Journal of Counseling Psychology, 
34:205-213, 1987. 

Swaim, R.C. Childhood risk factors and adolescent drug and alcohol abuse. 
Educational Psychology Review, 3(4):363-398, 1991. 

Trimble, J.E. The Sojourner in the American Indian Community: Methodologi- 
cal Issues and Concern. Journal of Social Issues, 34(4): 159-1 74, 1977. 



258 



11 



American Indian Alcohol 

Prevention Research: 

A Community 

Advocate's Perspective 

Jerry D, Stubben 



Introduction 

The prevention of alcohol abuse is the key factor in overcoming 
alcohol-related problems in American Indian communities, 
whether reservation, rural, or urban (May, 1992). Prevention 
modalities, techniques, beliefs, and values vary greatly from one 
American Indian community to the next. Conducting prevention 
research on American Indian populations requires a great deal 
of creative thinking. Many of the objective empirical techniques 
that may work with non-Indian populations may not prove valid 
or reliable in the measures of the effectiveness of American Indian 
community-based prevention programs (Thurman, 1992; May, 
1992). This is so because many of these measures do not embrace 
the traditional beliefs, practices, history, and values of the Ameri- 
can Indian community (Thurman, 1992). 

This paper is written from the perspective of the American 
Indian by a community advocate and strategist interested in 
promoting the prevention of alcohol-related problems in the 
Indian community. The contents of this paper draw heavily from 
several sources and represent a synthesis of ideas from: (1) the 









259 



two preceding papers in this volume on American Indians (May, 
Thurman); (2) other papers presented at the National Institute 
on Alcohol Abuse and Alcoholism (NIAAA) Working Group on 
Alcohol Prevention Research in Ethnic Communities held in May 
1992 and published in this volume; (3) discussion comments 
made by a variety of participants at the working group; (4) the 
experiences and research knowledge of the author, who is an 
advocate for community-based studies and programs to prevent 
alcohol-related problems in the American Indian community. 

Current Use of Alcohol Among 
American Indians 

Although American Indian drinking has received a great deal 
of attention for many years from a variety of people, prevention 
efforts have only begun to emerge in the past 20 years. The 
literature on prevalence of drug abuse among American Indians 
indicates that alcohol and other drug use vary tremendously 
from one tribe to the next (Levy and Kunitz, 1974; Heidenreich, 
1976; Mail and McDonald, 1980; May, 1977, 1982, 1986; Oetting, 
et al., 1980, 1983). Some tribes have fewer drinking adults propor- 
tionately than the U.S. population, whereas other tribes have 
more drinkers (May, 1992). Drinking patterns within the tribe 
can vary as well, as in the case of the Navajo (Topper, 1985; 
May, 1992). The majority of Indian youth of most tribes report 
experimentation with alcohol and a higher percentage of Indian 
youth report use of marihuana than other U.S. youth, but there 
is a wide intertribal variation (Heindenreich, 1976; Edwards and 
Edwards, 1989). Misuse of inhalants is a greater problem among 
Indian than among other U.S. youth (May, 1986; Thurman, 1992). 
Explanations for Indian alcoholism abound, but no single 
explanation can adequately account for all American Indian alco- 
hol problems. The heterogeneity of the Indian population (tribal 
custom, degree of acculturation or urbanization, geographic iso- 
lation) has hampered or precluded drinking problem surveys 
which permit generalizations (Lex, 1985). The character of Ameri- 
can Indian drinking — alternate binge drinking and abstinence, 
solitary vs. social drinking, relationships between drinking style 



260 



and acculturation, and adoption of anti-alcohol religious ideolo- 
gies — are examples of typical foci of drinking ethnography 
(Aberle, 1966; MacAndrew and Edgerton, 1969; Levy and Kunitv, 
1974; Heindenreich, 1976; Hill, 1990). The degree of cultural anxi- 
ety and variations in tribal custom and history have been offered 
as factors in differences in drinking patterns among tribes. Mis- 
use of alcohol is seen as an expression of the level of anxiety 
withrn the community (Field, 1962; Topper, 1985). 

Knowledge of the drug abuse history, drinking patterns, etc. 
within a community is essential to conducting prevention 
research or in the development of community-based prevention 
programs for that particular community. In addition, the histori- 
cal knowledge of the particular tribe under study is needed. 
Examples include: (1) knowledge of the treaty relationship 
between the tribe and the Federal Government, (2) boarding 
school experiences, and (3) most important of all, knowledge of 
the degree of the role of the Federal Government in determining 
and approving policies affecting tribal life, including drug abuse 
prevention policy (May, Moran, Stubben, Thurman, this 
volume). 

Such information can best be gathered by extensive and long- 
term on-site visits to the tribal community. Through such 
extended contact the researcher becomes experimentallv familiar 
with the community (Gilbert, this volume). Consequently, this 
ongoing relationship allows for more acceptance of the researcher 
by the community (Moran, this volume). An in-depth knowledge 
of the community will also provide assurance to grant reviewers 
at NIAAA that those applicants who seek funding to conduct 
multi-tribal prevention studies are culturally competent 
researchers (Gilbert, this volume). 

Culturally Competent Community- 
Based Prevention Among 
American Indians 

The following section discusses coirimunity involvement in pre- 
vention programmatic delivery and research in the areas of com- 






261 



munity resources, issues of biculturalism and program effective- 
ness. There was a general consensus at the working group that 
community-based prevention programs must involve the com- 
munity in all aspects of the prevention process. Moran (this 
volume) identified a prevention program among the Salish and 
Kootenai Tribes that included cultural committees which advised 
both the prevention and treatment staffs. Such community 
involvement gave the community a strong sense of ownership 
of the programs. May (1992) also identified a high degree of 
involvement among the Navajo in prevention and treatment 
programs within the various communities on their reservation. 
Thurman (1992) offered evidence that such community involve- 
ment must also be a key component in prevention programs for 
urban Indians as well. 

Community Resource Issues 

Stubben (this volume) discussed several instances where 
community resources could be utilized to deal with communica- 
tion and value differences in the development and implementa- 
tion of prevention programs within American Indian communi- 
ties. He compared community members to translators of commu- 
nity beliefs, norms, values, personal and tribal histories, and even 
language. The extended family and other cultural relationships in 
American Indian communities play crucial roles in aiding or 
abetting prevention programs utilized in such communities. 
What may seem to be a dysfunctional family relationship from 
the majority population (Western society) viewpoint may not be 
similarly viewed from the specific tribal viewpoint. 

Community members are a valuable resource because they 
can identify and define the differences in values between the 
Indian and Western worlds that make it difficult for the Indian 
person to avoid conflict in his or her daily life and to maintain 
balance and harmony in one's life direction. Learning to cope 
in both worlds is what most Indians are asked to do, particularly 
the young and middle-aged (Nieto, 1992). This acculturation 
pressure promotes drug abuse (Beauvais and LaBoueff, 1985; 
Bobo, 1985; Walker and Kivlahan, 1984; Topper, 1985). Accultura- 



262 



tion is stressful (Topper, 1985), and alcohol, tobacco, and other 
drugs offer coping responses (Trimble, Bryan, and Padilla, 1985). 
Lack of adequate cultural and personal skills necessary to cope 
with acculturation increases the likelihood for alcohol and other 
drug misuse, particularly in adolescence and the early twenties 
(Mail, 1985). 

Bicultural Pressures 

American Indian prevention and treatment programs must 
cope with these bicultural pressures in assessing the needs of this 
special population because many of the prevention and treatment 
modalities that may seem appropriate for other populations are 
not appropriate for American Indians (NIAAA, 1986). Previous 
research has identified that psychological counseling and referral 
to Non-Indian Alcoholics Anonymous (AA) chapters that are 
traditional in white Anglo-American mainstream alcoholism 
treatment may not appeal to many American Indians because 
of AA's public disclosure of personal problems, dominant Anglo- 
American religious overtones, exclusion of nonalcoholics, and 
attempts to influence the behavior of others. Likewise, many of 
the risk indicators that are traditionally used to identify potential 
alcohol use among youth, such as academic failure, permissive 
parental practices, or extreme economic deprivation practices, 
may not be useful or may have to be culturally interpreted in the 
prediction of alcohol use among an American Indian population 
(Medicine, 1983; Colorado, 1985; May, 1986; NIAAA, 1986; Grob- 
smith, 1989; Poor Thunder, 1991; Stubben, 1992). 

The problems and explanations of drug abuse among Ameri- 
can Indian and Alaska Native people call for new approaches 
to preventive intervention. Conceptually, these approaches must 
take into account the impact of both the traditional and the 
modern cultures upon the individual and their use or misuse of 
drugs (May, 1986). LaFromboise (1982) identifies that alcohol and 
other drug problem prevention programs for American Indians 
must "blend the adaptive values and roles of both the culture 
in which one is raised and the culture by which one is sur- 
rounded" (p. 12). May (1986, 1992) identified that a shortcoming 



i > 



263 



< 



of many such prevention programs is their inability to educate 
American Indians about the social and physical impact that mis- 
use has upon the individual and community. Prevention ' 'pro- 
grams must aspire to research, understand and decrease morbid- 
ity and mortality" through ' 'increased health education, policy 
initiatives, increased community awareness of solutions" (May, 
this volume). Such health education programs must elevate the 
knowledge of American Indians about alcohol and other drug 
misuse through increased use of both traditional tribal strengths 
and modern prevention and treatment modalities. 

However, a basic concern exists as to whether a bicultural 
approach to contending with the dominant American culture is 
a viable option for Indian people. Biculturalism refers to dual 
modes of social behavior that are appropriately employed in 
different situations. Some Indian observers believe that a func- 
tionally effective bicultural lifestyle is a myth, that those who 
attempt to practice it will necessarily become ineffectively stran- 
ded between two cultures (Schinke, et al., 1986). They believe, 
for instance, that one lifestyle will necessarily replace the other 
(Leon, 1968) or that personal preference and commitment to one 
lifestyle will predominate (Charleston, 1980). Others, however, 
suggest that effective functioning in two cultures leads to greater 
self-actualization (Dinges, Yazzie, and Tollefson, 1974; LaFrom- 
boise, 1982; LaFromboise and Rowe, 1983; May, 1986). 

In fact, previous research has identified that the better inte- 
grated one is to both Indian and modern systems, the less the 
susceptibility to drug misuse. Indians who have meaningful roles 
in both traditional and modern cultures have the lowest suscepti- 
bility to alcohol and other drug misuse. Those with highest risk 
for misuse are marginal to both Indian traditional and modern 
cultures (Ferguson, 1976; May, 1982, 1986, this volume; NIMH, 
1986; Schinke, et al, 1986). 

Nieto (1992) asserts that those who have reached full develop- 
ment in two cultures have reached a state of additive multicultur- 
alism and enjoy cognitive advantages over monoculturals 
through a broader view of reality, feeling comfortable in a variety 
of settings, and multicultural flexibility (p. 271). The knowledge 
of two languages is a key factor in additive multiculturalism 



264 



and should be tested in terms of ability among prevention staff, 
participants, non-participants and the community. Wilson (1991) 
pointed out that children in the Loneman Schools on the Pine 
Ridge Reservation in South Dakota did better on achievement 
tests if they were taught in both Lakota and English. 

Prevention programs face a similar dilemma. Previous 
research indicates that prevention programs based solely on an 
Indian person's identification with Indian culture, although hav- 
ing some effect, are weakened because they do not deal signifi- 
cantly enough with external acculturation problems, such as 
school performance or the legal system (Oetting, et al., 1989). 
On the other hand, in recent interviews Stubben (1992) found 
that the utilization of a cultural component in alcohol treatment 
among American Indians, such as a sweat lodge or talking circle, 
improved their chances for recovery nearly five times over the £; 

lack of such a cultural component. Those prevention (and /or 
treatment) programs that are marginal to both Indian traditional 
and modern prevention modalities have been found to have the 
greatest chance of failure (LaFromboise and Rowe, 1983; Oetting 
et al, 1989; Stubben, 1992). 

Furthermore, research on incarcerated American Indians 
identifies the impact of cultural factors upon sobriety. The major- 
ity of Indian inmates who were incarcerated for alcohol-related 
crimes found sobriety through traditional practices, if available. 
Inmates who had little acquaintance with their ancestral tradi- 
tions prior to their incarceration, as well as inmates whose tradi- 
tional practices were intact, enjoy deep involvement in religious 
activities and cite this involvement as being primarily responsible 
for their commitment to maintain sobriety. Since gaining access 
to illegal drugs in prison does not pose as much of a problem 
as it would for youth or adults on many reservations, those 
who abstained from drug and alcohol use stated that they were 
motivated to do so through a religious commitment to the "good 
Red Road," to "walking with the Pipe," or "walking the Peyote 
Road" (Grobsmith, 1989). In South Dakota, the switch from AA- 
based group meetings to Red Road group meetings increased 
the attendance of the American Indian populations from 20% in 
previous AA meetings to 80% in Red Road meetings (Sander- 
son, 1991). 



265 



Program Effectiveness Issues 

Research on the effectiveness of culturally competent drug 
abuse treatment programs indicates that treatment programs 
that reflect Indian culture and incorporate native religious beliefs 
seem to be meeting with more success than those that don't 
incorporate a cultural component (Mail and McDonald, 1980; 
Moran, this volume; Stubben, 1992). Hall (1986) documents the 
effectiveness of treatment programs which include the Sweat 
Lodge and Sun Dance. Hill (1990) described the preventive 
nature of the Native American Church, as did Slagle and Weibel- 
Orlando (1986) with the Indian Shaker Church and A A Curing 
Cults. Evaluating the impact of the integration of such culturally 
traditional prevention modalities into community-based preven- 
tion program needs to be emphasized in future alcohol preven- 
tion evaluation and research. Funding for evaluation research 
on such ' 'alternative" methods of drug abuse prevention and 
treatment must become a priority in the near future. The impor- 
tance of this issue was reaffirmed by the "Working Group" 
because of the fact that many American Indian community-based 
prevention and treatment programs are presently utilizing their 
own tribally based prevention and treatment techniques, and 
these must be evaluated in order to prove or disprove their 
validity. 

In fact, many American Indian communities rely only on 
their own tribally based prevention practices or totally adjust 
external prevention programs to these practices. Culturally rele- 
vant evaluation will measure the validity of such tribally based/ 
culturally competent programs and may increase the utilization 
of tribally based /culturally competent prevention programs 
among all American Indian communities. 

Evaluations of tribally based programs must be conducted 
by culturally competent researchers. Researchers with no or even 
a limited degree of cultural competence may actually do more 
harm than good in evaluating such prevention programs, since 
their findings may be so value biased that they identify situations 
that do not actually exist. 

For example, Moran (this volume) discussed an evaluation 
of a prevention program in the Barrow community of Alaska 



266 



c ,; 

-• . 






that was contracted to outside, non-Indian researchers. After 
conducting their evaluation, the outside researchers presented 
their findings to a community steering committee that had ini- 
tially assisted them with access to the community. A draft of the 
evaluation was circulated to the steering committee, who felt it 
was difficult to read, verbose, and ambiguous. Foulks (1989) 
explained that the draft was seen as imposing outside standards 
on the native society without reflecting attitudes and values of the 
community. After major attempts to rectify the aforementioned 
dilemma, the researchers made another major blunder when the 
researchers 7 findings were released by an external agency at a 
press conference in Philadelphia. The news release was picked 
up by the national wire services and received widespread and 
sensational coverage. The community was surprised and angered 
by the "unauthorized" public exposure which brought shame & 

on the community. Access to further community information 
was denied, as a large segment of the community refused to 
participate further in the evaluation (Foulks, 1989). 

An evaluation of prevention and treatment programs among 
the Salish and Kootenai tribes was directed by an American 
Indian researcher from a local university who had extensive 
experience in both alcohol-related research and in evaluating 
American Indian prevention programs among several different 
tribes. This evaluation obtained a vast amount of information 
from the community, due in part to the long-term relationship 
that the researcher had with the community. Important informa- 
tion was offered freely by the community to the researcher, who 
had become a trusted member of the community (Moran, 1992). 

Culturally Competent Community- 
Based Prevention Research 
Among American Indians 

May, Moran, Stubben and Thurman emphasize in this volume 
that the researcher who is not part of the community being 
studied, must recognize the effect of the researcher's own values 
and beliefs upon the research design, data collection instruments, 



267 



data collection, even data entry and research conclusions. For 
example, a researcher who adheres to the health education pre- 
vention model may overlook the effects of traditional healing 
practices upon community-based prevention programs. Bias is 
a major impediment to reliable and valid drug abuse research 
and evaluation. 



Bias Issues 

Further discussion among the members of the working group 
suggested that perhaps the most effective method to deal with 
bias is to include members of the community into every aspect 
of the research. In such a situation, the principal investigator 
would identify members of the community who possess the 
education necessary to understand and express opinions on the 
validity and reliability of the research design. This would be done 
«jj fc in the early stages of the development of the research design. 

An "academic bias" may come to exist in the selection process 
of the community members chosen to evaluate the research 






design and assist in the research. If the researcher cannot find 
a fellow scientist within the particular community, other commu- 
nity members can be found who possess the knowledge neces- 
sary to assist with the research design or any aspect of the 
research (May, Thurman, this volume). It means that the princi- 
pal investigator and the funding agency must adjust their own 
beliefs and values in order to accommodate the beliefs and values 
of the community, particularly those beliefs associated with edu- 
cational credentials (Stubben, 1992). 

Two examples of value differences, cultural terminology and 
tribal hiring practices, add credence to the aforementioned value 
conflicts that may arise in culturally competent research. In terms 
of life experiences, Moran identified a similarity of knowledge, 
beliefs, value statements, and writing style. These were recog- 
nized by the American Indian participants among themselves 
from the papers submitted and discussions during the "Working 
Group" sessions. Other minority group members, however, did 
not pick up on these. An example is the utilization of particular 
words and phrases (such as termination, elder, eagle feather), 



268 



mannerisms, and even acknowledgment of geographic territory 
of each person's tribe. Other participants did not pick up on these. 
The other example came from a non-Indian participant in 
the working group who spoke of how an American Indian com- 
munity member who was in charge of hiring data collection 
personnel tended to hire his relatives. This tribal practice was 
in violation of the values of the researcher and the society at 
large. Yet, from a community view, it added validity to the 
research because the members of the community who were inter- 
viewed could see that the community member in charge of hiring 
was following the tribal practice of "taking care of one's family 
or clan." In many American Indian communities one's credibil- 
ity in the community is judged by how one treats one's family 
or clan. If one's relatives are suffering, then how can that person 
be expected to care about the rest of the community? Such com- 
munity beliefs and values need to be accounted for, or else the 
research data collected maybe unreliable and /or invalid (Gilbert, 
May, Moran, Stubben, Thurman, this volume). 

• 



Issues of Norms and Practices 

Community norms and practices in a particular American 
Indian community may not fit those of the community that the 
researcher has grown up in or presently lives in. An example of 
this was evidenced by a researcher who was conducting inter- 
views among a group of Plains Indian tribes in regard to obesity. 
She went in asking questions about dietary habits, physical activ- 
ity, and health information delivery. But after two months of 
questioning it was brought to her attention that being overweight 
was considered by some clans as a sign of successful living, 
having plenty of food. This thought process had evolved from 
the past, when food was scarce and had high value among the 
tribe (Stubben, 1993). 

This researcher had great difficulty understanding how an 
"ancient" belief could influence eating habits among a fairly 
large segment of the tribes interviewed, even after years of health 
information that obesity is a health hazard had been delivered 
to tribal members by IHS and tribal health prevention programs. 
A further finding revealed that government commodities that 



V 






269 



S 03 



:• ... 



are distributed freely to and consumed by many tribal members 
are full of fat and high in calories. The researcher was eventually 
convinced by tribal members who assisted with and reviewed 
the research that she must report in her research findings that 
both past tribal beliefs and present government policies were 
the major reasons for the high level of obesity among these tribes. 
Obesity prevention programs among these tribes need to take 
into consideration past tribal beliefs when redesigning preven- 
tion programs (Stubben, 1993). 

May (1992) noted in his paper and discussion that many 
times researchers go into an American Indian community with 
a view that everything is wrong and nobody is doing anything 
about it. May stated that this viewpoint is wrong and ignores 
the major changes that are occurring in American Indian commu- 
nities all across this land in dealing with and conquering drug 
abuse. For example, socio-economic indicators utilized in other 
communities as indicators of drug abuse may not be as valid with 
American Indian communities. The values and even educational 
background of the researcher and evaluator may prevent them 
from adjusting their research to the particular epidemiology of 
the community, from seeing the positive aspects of the commu- 
nity, and the culturally specific practices that the community 
utilizes in dealing with drug abuse. 

For example, Medicine (1983) wrote of the common practice 
among Lakota women to totally abstain from alcohol and other 
drugs for the rest of their lives after becoming a grandmother 
and reaching the high status of an elder. Researchers may have 
difficulty understanding how such events as becoming a grand- 
parent or having a spiritual vision through ceremony could be 
considered as preventing drug abuse. Yet, such major events in 
an Indian person's life tend to prevent drug abuse more than 
other practices and models in many tribes and communities. A 
researcher without the cultural competence to understand such 
events may not recognize them or their significance in conducting 
a community-based prevention evaluation. 

Research Issues 

The use of community members in the design of the data 
collection instruments, data collection, and coding of data can 



270 



a 



be very helpful. Community members who speak the language, 
understand physical movements and verbal reflection, and /or 
live with the community's beliefs, practices, and values daily 
can prevent the types of problems that make the results of the 
research invalid. In the use of community members as data collec- 
tors, the researcher must identify through community members 
(1) the respected members of the community to utilize, (2) tribal 
norms on disclosure of personal information, (3) intertribal dis- 
putes between families, bands, clans, (4) age and gender norms, 
and (5) the degree of assimilation among tribal members. Be 
flexible; some tribes may require a community meeting to intro- 
duce both the principal investigator and co-investigators and the 
community members involved in the research. At this commu- 
nity meeting other community members can be identified who 
may have to be included in the research team for success. 

In conducting interviews, several techniques may be 
required. For example, the principal investigator should inter- 
view a sample of the community alone, then have interviewers 
from the community interview another sample, and then have 
the principal investigator and interviewers from the community 
interview another sample together. The results of these inter- 
views should then be compared to identify value differences. In 
utilizing written, self-completion survey forms, a community 
member may have to be present while individuals are filling out 
such forms in order to answer questions about the questions or 
the form itself. Also, the research team should use different types 
of forms on different samples of the community. The survey 
forms should include questions that are community specific as 
well as the general questions utilized in most drug abuse 
research. The utilization of questions that identify the respon- 
dent's view of local culture, norms, and values may be more 
important than identifying his or her use of alcohol. For example, 
should the community have a bar? Do you personally know any 
bootleggers in your community? Is it all right for a tribal council 
member to drink alcohol? If a person has a problem with alcohol, 
where should they go for help? What is a sweat lodge ceremony? 

Therefore, a complete prevention program in an American 
Indian community must be built on the particular epidemiology 



271 



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i . 


N., 












CO 




■• 




.„. 












i 


■ • 






L 



of the area and designed with local beliefs, culture, norms, prac- 
tices, traditions, values, and conditions in mind. Likewise, 
research on the effectiveness of such prevention programs must 
involve community members to as high a degree as possible in 
order to take into account the impact of such local beliefs, culture, 
norms, practices, traditions, values, and conditions on the pre- 
vention of drug abuse in the particular community under study 
(NIMH, 1986; Thurman, May, Moran, Stubben, this volume). 

Although community members need to be involved in all 
aspects of the research, that does not mean that every area of 
the community is involved. Thus, research progress, findings, 
problems, and conclusions should be presented to the tribal 
governing body, elder councils, and other community groups in 
order to both inform and gather further information. Also, the 
principal investigator needs to make him or herself available 
to the community for informal conversations, gatherings, and 
meetings, etc., without being intrusive. In other words, if invited 
to community functions by a community member, the researcher 
should attend. If not invited, the researcher should stay away. 

Any research that is conducted within American Indian com- 
munities should reward the community for its participation. 
Employment of tribal members in all aspects of the research can 
improve the economic condition of even a small segment of the 
tribe. Indirect costs to the community (staff time, office space, 
housing, community travel, utilities, knowledge that is not 
directly paid for, inconvenience, etc.) could be taken into account 
within the initial grant proposal. Funding for community gather- 
ings such as pow-wows, dinner (cooked and served by commu- 
nity members), school events, community meetings, elder meal 
and gathering, give-away, awards, etc., should be included in 
each grant application. Also, some of the computer equipment, 
paper, books, etc. purchased through grant funds could stay 
in the community after the research is completed — possibly in 
the schools. 

Although minority supplement grants are presently available 
for post-doctorate minority researchers, additional scholarship 
and mentorship funding for both undergraduate and graduate 
minority students could be included in or linked to present or 
future prevention grants. American Indian and non-Indian aca- 



272 



demies could identify members of the community or other Amer- 
ican Indians who are presently or soon will be attending college 
who may be interested in seeking academic training in preven- 
tion and treatment research. Those who want to pursue an initial 
academic degree or go to graduate school could be offered schol- 
arships to the academic institution(s) that receive Federal funding 
for prevention research among American Indian communities. 
As is the case with minority supplement grants, mentors should 
also be available at these institutions for these students. 

Research projects among American Indian communities must 
be long-term commitments. One cannot learn from an American 
Indian community unless one is willing to expend the time to 
learn. Future funding of prevention research projects should be 
for a minimum of five years. Funding should be available for 
the principal investigator(s) and co-principal investigators, who 
are not community members, to either live in the community 
year round, with regular visits to their academic institution, or 
make extended visits in the community on a regular basis. Since 
some prevention research projects may require visits to more 
than one American Indian community, funding for prolonged 
stays in or visits to each community are necessary. 

One recommendation that came out of the discussions of the 
' 'working group" was a need for researchers and prevention 
staff to have a total understanding of themselves before ever 
setting foot in an American Indian community. The following 
statement flowed throughout this discussion: "One must know 
one's own values and beliefs before one can understand the 
values and beliefs of another." In other words, it is important 
not only that the researcher or prevention specialist who works 
with an American Indian community attempt to be as culturally 
competent in regard to the community that he or she is working 
with, but also they must be culturally competent about their 
own heritage and cultural background (Moran, Stubben, Thur- 
man, this volume). 

In terms of future research, despite a strong theoretical base 
and the promising initial support for culturally competent pre- 
vention programs, several important dimensions of evaluation 
will be required to clarify the potential impact of such prevention 
programs (May, 1986, and May, 1992). First, culturally competent 



273 



prevention programs for American Indians have not been sub- 
mitted to a randomized, controlled efficacy study with long- 
term followup evaluation of the impact of such programs on risk 
and protective factors for alcohol problems. Second, although 
studies on the impact of prevention programs on risk and protec- 
tive factors have been conducted on American Indian popula- 
tions (Mail and McDonald, 1980; May, 1986), prior assessment 
has not measured the impact of the cultural components of pre- 
vention programs for American Indians upon these risk and 
protective factors (LaFromboise, 1982). Third, there has not been 
controlled, comprehensive measurement as to the impact of cul- 
turally competent drug abuse prevention programs on commu- 
nity perspectives of alcohol misuse. Alcohol misuse does affect 
every American Indian community, yet little or no research has 
been conducted upon how the community deals with the preven- 
tion of drug abuse from its own cultural perspective (Flute, et 
al., 1985; Poor Thunder, 1991; Wilson, 1991). Fourth, there is a 
"'■ v I need to bring the research and tribal communities closer together 



in order to be able to accomplish the aforementioned objectives 
and to develop culturally competent prevention programs based 






upon culturally relevant research findings. 

In conclusion, one research or prevention model will not 
accommodate the variety that exists within American Indian 
communities and among the people who inhabit them. American 
Indian tribes maintain their cultural differences in order to main- 
tain themselves as Indians. That is why any research or preven- 
tion model that attempts to integrate the values, beliefs, or even 
medical practices of the non-Indian world into the community 
world view will fail (Stubben, 1992). The researcher or prevention 
professional must allow the American Indian community to 
adjust such models to fit their particular community. For, in 
doing so, the cultural uniqueness of the community continues, 
the tribe maintains its identity, the researcher obtains valid and 
reliable data, and the prevention program is a success (Thurman). 

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12 

The Prevention of 

Alcohol-Related 

Problems Among United 

States Hispanics: A Review 

Raul Caetano 



Introduction 

Heavy drinking, alcohol dependence and alcohol-related prob- 
lems are complex phenomena whose origin is rooted in a variety 
of individual, cultural and societal factors. Society's attempt to 
respond to these problems was for a long time based mainly on 
the provision of treatment for those in need. Recently, recognition 
of the complexity of these problems and increased acceptance 
of public health paradigms have made prevention intervention 
and prevention research an important part of the response to 
alcohol-related problems. For instance, in the mid-1970s the 
National Institute on Alcohol Abuse and Alcoholism (NIAAA) 
created a Prevention Division (Room, 1990), and in 1983 it funded 
a national center whose focus is prevention research. In 1988 



Work on this paper was supported by a National Alcohol 

Research Center grant to the Alcohol Research Group, 

California Pacific Medical Center Research Institute, 

Berkeley, California. 



279 



NIAAA established a Prevention Research Branch within a new 
division of clinical and prevention research (Howard, 1990). In 
1986 the Office of Substance Abuse Prevention (SAP) was created 
to provide federal leadership for prevention activities in the 
substance abuse area (Johnson, 1990). 

Prevention activities and research have become more and 
more diverse and sophisticated, and a large and varied literature 
on this topic now exists. This literature has been reviewed by 
many, with reviews focusing on educational strategies (Blane, 
1976; Moskowitz, 1989), media campaigns (Wallack, 1981, 1985; 
Hewitt and Blane, 1984), alcohol control measures (Bruun, et al., 
1975), and community action projects (Giesbrecht, et al., 1990). 
This paper reviews a part of this literature, i.e., recent community 
studies directed at the prevention of alcohol-related problems 
among U.S. Hispanics. Three previous papers have had this 
focus, two discussing prevention among Mexican Americans 
(Ames and Mora, 1988; Gilbert and Cervantes, 1987) and a third 



discussing prevention and other responses to alcohol-related 



problems among Hispanics (Caetano, 1988). 






This review is organized as follows: The first section describes 
characteristics of Hispanics' history in the U.S., their migration, 
demographic composition, cultural diversity, development of 
ethnic identity and acculturation. These historical and sociode- 
mographic characteristics are important for understanding the 
culture in which Hispanics' drinking habits are rooted and for 
developing and implementing prevention interventions in this 
ethnic group. The second section reviews research findings on 
drinking patterns and alcohol problems among Hispanics, and 
discusses a framework for understanding drinking and problem 
drinking among Hispanics. The third section reviews community 
studies for the prevention of alcohol-related problems conducted 
among Hispanics, assessing the reasons for their success or fail- 
ure. The fourth section discusses the evidence regarding the need 
for "culturally sensitivity" in prevention interventions, and its 
relationship to the effectiveness of such strategies. The fifth sec- 
tion suggests ways to disseminate research findings that can 
be used to prevent alcohol-related problems. Such review will, 
hopefully, provide subsidies for the continuing development of 
prevention research focused on Hispanics. 



280 



Hispanics in the United States: 
Origin, Migration, and Growth 

Hispanics' presence in the Southwest of what is now the United 
States can be traced back to the 15th and 16th centuries. At that 
time land occupation was mainly done by Spanish expeditions 
in search of silver and gold. During the 17th and the initial part 
of the 18th century land occupation was done to develop mining, 
establish missions and Christianize the Indians, and to counteract 
foreign interests in the region. During the 1800s a series of impor- 
tant political events such as the Mexican war of independence, 
American expansion to the Southwest, and the U.S.- Mexican 
war changed the face of colonization. These political events 
resulted in 1848 in the treaty of Guadeloupe-Hidalgo between 
U.S. and Mexico and the annexation to the U.S. of what is now 
Arizona, California, Colorado, New Mexico and Texas, as well 
as parts of Utah and Nevada. Later, in 1853, an additional area of 
45,535 miles was, purchased from Mexico through the Gadsden 
Purchase, completing the present shape of the border between 
U.S. and Mexico. The annexation marks the beginning of the 
history of Hispanics as an ethnic minority group in the U.S. 

According to Moore and Pachon (1976), there were approxi- 
mately 75,000 individuals of Mexican background living in New 
Mexico, Texas, Arizona and California when the treaty of Guade- 
loupe-Hidalgo was signed. Loosley (1927) indicates that accord- 
ing to the U.S. Census of 1850 there were 6,454 Mexicans in 
California. Since 1850 the Hispanic population has grown at a 
larger pace than the U.S. general population through migration 
and a higher than average birth rate. Migration from Mexico 
and other Latin American countries waxed and waned through- 
out this century following economic fluctuations and changes 
in immigration policies. At times of economic expansion the 
immigrants were welcomed. At times of depression the reverse 
was true. Irnrnigration activities to stop illegal entry, a phenome- 
non as old as the creation of the border between U.S. and Mexico, 
have also varied in intensity. During the mid-1950s, "Operation 
Wetback" was launched by the Immigration Service to stop ille- 



281 



gal entry into the country, resulting in the expelling of 3.8 million 
Mexicans from the U.S. 

Nowadays, preliminary figures from the 1990 Census indi- 
cate that Hispanics constitute about 9% of the U.S. population 
(U.S. Bureau of the Census, 1991). Mexican Americans are the 
largest national group among Hispanics, followed by Puerto 
Ricans and then by Cuban Americans. Most Mexican Americans 
live in the Southwest, with Puerto Ricans concentrated in the 
New York area and Cuban Americans in Miami. However, there 
already are large populations of Mexican Americans living in 
the Midwest (e.g., Chicago), as there are considerable numbers 
of Central Americans in certain metropolitan areas (e.g., San 
Francisco). 

The history of Puerto Ricans in the U.S., the second largest 
e group of Hispanics, is as rich and complex as that of Mexican 

Americans. Puerto Ricans have, however, a particular character- 
& fc v istic that sets them aside from other Hispanic national groups. 

Given the political situation of Puerto Rico, they are all U.S. 
'■': citizens independent of whether they are born in the U.S. main- 

land or in the island. Thus, they are not subject to the same 
immigration laws that govern the entry of other Hispanic 
national groups into the U.S. Cuban Americans' presence in the 
U.S. increased considerably after Fidel Castro's revolution in 
Cuba. That change in political regime brought a great number 
of Cubans to the U.S., many of whom were not poor and disen- 
franchised as the Mexican peasants who came to the Southwest, 
but belonged to the Cuban professional class. Subsequent migra- 
tion waves have had a different socioeconomic characteristic. 
However, contrary to other immigrants from Latin America, 
Cuban Americans have always been seen by the Immigration 
Department as political rather than economic refugees, and as 
such have had an easier entry into the U.S. 

Hispanics are therefore a very heterogeneous group. The 
culture they bring from their countries of origin marks the begin- 
ning of their life in the U.S. and the patterns of interaction that 
they will have with American culture. Contrary to the European 
immigrants that came to the U.S. around the turn of this century, 
many Hispanics are not Whites but "brown/' This too has set 



282 



them apart from other immigrants, fostering discrimination 
which has helped to shape their history in the U.S. The heteroge- 
neity of Hispanics in the U.S. has created a debate around the 
use of the word Hispanic as a common identifier to this ethnic 
group (Aday, et al., 1980; Giadello et al., 1983; Hayes-Bautista, 
1980, 1983; Caetano, 1986a). Critics suggest that such a common 
label creates an illusion of cultural and social uniformity which 
leads to the development of uniform social and health policies 
that fail to respond adequately to the needs of U.S. Hispanics. 
This issue is of importance to the prevention field, and the ques- 
tion of whether prevention strategies need to address these cul- 
tural differences across different Hispanic national groups will 
be discussed below. 






Ethnic Identity and Acculturation 

Understanding the processes by which Hispanics and other eth- 
nic/racial groups develop their sense of affiliation with ethnic 
culture, i.e., their ethnic identity, is an important step for conduct- 
ing prevention research or implementing prevention strategies 
in ethnic/racial communities. Understanding the association 
between ethnic identity and acculturation to U.S. society is also 
important for this work. 

Ethnic identity for those irrirnigrant groups who came to the 
U.S. during the second part of the 19th century and the first 
decades of this century is said to have emerged more from these 
groups 7 experience of life in the U.S. than from some common 
identity brought from their homelands (Greeley, 1971; Wolf, 
1984; Room, 1985). With regard to Hispanics this process is differ- 
ent. Most immigrants from Latin America come with a sense of 
their national origin, and their pattern of geographical distribu- 
tion in the U.S. suggests a need to be with "their own." Ethnic 
identity for U.S.-born Hispanics follows a different process, being 
influenced by their experience of life in the U.S. vis-a-vis other 
ethnic groups and the majority society (Caetano and Medina 
Mora, 1988). Thus, in contrast with other immigrant groups in 
the U.S., Hispanics are not isolated from their culture of origin. 
This is especially true of Mexican Americans, for whom Mexico 



283 



is not an unreachable faraway mother country, but can be easily 
reached by car or even on foot, thus representing a continuous 
source of cultural reinforcement and renewal. The unrestricted 
movement of Puerto Ricans between the mainland and the island 
has a similar role in Puerto Rican life. 

Discussions of ethnic identity for U.S. Hispanics, and in par- 
ticular Mexican Americans, have been oriented around two ideas: 
Adherents of the "colonial analogy' ' think of Mexican Americans 
as a conquered people (Moore and Pachon, 1976; Alvarez, 1985) 
and believe that their experience of ethnic identity development 
is different from that of other ethnic groups in the U.S. Others 
(Padilla, 1985 Fishman, 1985; McLemore and Romo, 1985) argue 
that there were very few Mexicans living in the U.S. Southwest 
at the time of annexation to characterize Mexican Americans as 
a conquered people. They also argue that Mexican Americans 
do not see the Southwest as their "homeland" (Connor, 1985), 
a necessary condition for characterizing their status as a con- 
quered people. 

The existence of ethnic identity does not preclude the devel- 
opment of an overall American identity. McLemore and Romo 
(1985) talk about "alternate identities"; Fishman (1985) refers to 
mainstream (American) and sidestream ethnicity; and Gordon 
(1964) discusses the notion of ethnic identity layers. Yinger (1985) 
and Fishman (1985) suggest that the implementation of ethnic 
identity is to a great extent situational. Birth, death, marriage 
and relationships with parents and siblings seem to occur within 
the territory of ethnic groups. Religion and entertainment are 
also more connected with ethnic culture than work. Relationships 
with governmental institutions are largely non-ethnic. Educa- 
tional and work-related activities may be ethnically enclosed, 
non-ethnic or mixed, depending on a variety of circumstances 
associated with the situations in which such activities occur. 
Social class attributes also color these activities. Gordon (1964) 
has introduced the concept of "ethclass" to represent what he 
believes to be the main orientation of an individual, that repre- 
sented by a cross-section of ethnicity and class. 

Within this framework, acculturation is a process by which 
Hispanics balance these layers of identity, adopting with varying 



284 



degrees of intensity the mores and values of the majority society. 
Thus, there can be acculturation to U.S. society in some areas of 
life but not in others. Personal factors as well as factors in the 
surrounding environment will contribute to these choices. His- 
panics who come to the U.S. of their own choice may acculturate 
in a manner different from those who come because of political 
persecution in their homeland. Coming to live in East Los 
Angeles may lead to a different acculturation process than com- 
ing to live in Brownsville or Chicago. As will be seen below, 
acculturation is a strong determinant of alcohol use among His- 
panics, and as such it also is an important factor to consider in 
prevention research. 

Alcohol Use and Related Problems 
Among Hispanics 

The alcohol literature on Hispanics has been the subject of a 
number of reviews (Alcocer, 1982; Caetano, 1983; Gilbert and 
Cervantes, 1987). This section reviews the main epidemiological 
findings which suggest target groups for prevention interven- 
tions among Hispanics. Much of the review is based on findings 
from the 1984 national survey of Hispanics conducted by the 
Alcohol Research Group. The findings from the analyses of this 
survey have been reported in a series of papers, and have been 
recently summarized by Caetano (1991). 

Drinking Patterns Among Men 

Among Hispanic men the drinking pattern which is more closely 
related to alcohol problems and which should be the focus for 
prevention is frequent heavy drinking (drinking five or more 
drinks on occasion at least once a week). Hispanic men have a 
12-month rate of frequent heavy drinking lower than that for 
non-Hispanic men in the U.S. population (17% versus 24%). Most 
of this frequent heavy drinking among Hispanics occurs among 
men 30-39 years of age (26%), while among non-Hispanic men 
in the U.S. the peak of heavy drinking occurs in the 18-29 age 
group. Analyses by national groups show that Mexican American 
men drink more than Puerto Ricans and Cuban Americans. Mexi- 






285 



* Q 



can American men also have a higher proportion than men in 
the U.S. population who report drinking five or more drinks at 
a sitting (54% versus 42%). Other predictors of heavier drinking 
among Hispanic men are: having at least high school education, 
making $30,000 or more annually, being acculturated, being born 
in the U.S., and being separated or divorced. 

A proportion of the drinking done by Hispanic men is done 
in parks, streets and parking lots (26% of the men report drinking 
in these places). The mean number of drinks consumed in these 
public places is higher among Hispanics than among Whites and 
Blacks (Hispanics, 4.0; Whites, 3.1; Blacks, 2.5). The proportion 
of men who drink five or more drinks in these public settings 
is also higher among Hispanics than among Whites (Hispanics, 
7%; Whites, 2%; Blacks, 7%). The settings where heavier drinking 
is most common are bars and parties. Men who go at least three 
times a month to bars or public places such as parking lots and 
parks tend to be single and younger than other men. These men 
also have a higher rate of heavy drinking and drunkenness than 
other men. 

Drinking Problems Among Men 

About 18% of Hispanic men reported at least one alcohol problem 
in the past 12 months. Men in their 50s, those with some high 
school education, those with annual income lower than $30,000, 
those who are separated or divorced and those who are heavier 
; drinkers report more problems than other men. Among U.S.- 

born men, those who are first generation report more problems 
than others. Among foreign-born men, Mexicans report more 
problems than others. The most frequent problems are salience 
of drinking behavior, problems with spouse, problems with other 
people, impaired control and health problems. Data on arrests 
indicate that Hispanics are overrepresented among individuals 
arrested for drunk driving (Caetano, 1984; Ross, et al, 1991). 
Mortality data suggest that Hispanics have a high rate of deaths 
due to cirrhosis (Caetano, 1986b). 

Drinking Patterns Among Women 

Hispanic women have a higher rate of abstention than non- 
Hispanic women (46% versus 36%) and a lower rate of frequent 



286 



heavy drinking (2% versus 6%). Among Hispanic women, those 
in their 50s have the highest rate of frequent heavy drinking 
(8%). Among non-Hispanic women, the peak for frequent heavy 
drinking occurs among women 30-39 years of age (10%). The 
predictors of heavier drinking among Hispanic women are: being 
employed, having completed high school education or more, 
and being acculturated. 1 Mexican American women have a rate 
of frequent high maximum drinking (12%) higher than that of 
women in the other two major national groups (Puerto Ricans, 
3%; Cuban Americans, 7%). This higher rate of heavier drinking 
seems to be due to drinking done by Mexican American women 
who are U.S.-born and who are highly acculturated to the U.S. 
About 38% of these women (N = 95) are frequent high maxi- 
mum drinkers. 



Pi 






Drinking Problems Among Women 

Because they drink little, Hispanic women report few problems 
in comparison to men. The proportion of women reporting one 
or more problems in the past 12 months is 6%. Mexican American 
women and those who are U.S.-born report more problems than 
other women. Problems with highest prevalence are: salience of 
drinking behavior (3%); impaired control over drinking (3%); 
belligerence (3%); health problems (3%). Among Hispanic 
women, those who are single and those who are younger have 
a greater chance of having problems than other Hispanic women. 

Norms and Attitudes Toward Drinking 

Mexican Americans and Puerto Ricans have more liberal atti- 
tudes toward drinking and drunkenness than Cuban Americans. 
When norms are examined with regard to how much drinking 
is seen as appropriate for men and women in different age 
groups, there is considerable agreement that those who are 30 
or 40 years of age may drink more than others. With regard 
to norms concerned with drinking larger quantities of alcohol 
("drinking enough to feel the effects"), more Mexican Americans 
express approval of this type of drinking than Puerto Ricans or 
Cuban Americans. This is in accordance with Mexican Ameri- 



287 



cans' higher rate of heavier drinking and with their attitudes 
toward drunkenness. 

Drinking Patterns and Problems 

The results reviewed suggest that Hispanics who are in the upper 
socioeconomic groups drink more than others, but problems 
are more common among Hispanics with lower income. For 
Hispanics, drinking is seen as an activity that rewards the ful- 
fillment of family and work obligations of men who are in full 
adulthood and beyond. Yet, much drinking still occurs among 
young men in their twenties. Some of this drinking by men 
occurs in public places, on occasions when the amount of alcohol 
ingested is relatively high. Ingestion of such high amounts is 
more common among Mexican Americans than among Puerto 
Ricans and Cuban Americans. Employment and birth in the U.S. 
seem particularly important in lowering abstention and increas- 
ing rates of heavier drinking among women. When women who 
are employed are compared with homemakers, the effect of 
employment on abstention is independent of age and education. 
Income may certainly play a part in these differences, but the 
Hispanic woman who works is breaking away from tradition as 
well as from behaviors, such as abstention, that may be associated 
with it. 

Acculturation to U.S. society also plays an important part in 
shaping women's drinking. Women who are highly acculturated 
have 9 times greater chance of being heavier drinkers than do 
women in the low acculturation group. Acculturation also 
implies more liberal attitudes toward alcohol use and increased 
social opportunities to drink. Hispanics who are highly accultu- 
rated report more frequent attendance at a number of social 
settings where alcohol is often consumed (restaurants, clubs, 
bars, parties, home) as well as greater frequencies of drinking 
in these places. In general, these relationships are independent 
of income or work status. 

The change in drinking patterns associated with accultura- 
tion seems to occur more quickly for men than for women. After 
1 to 5 years of life in the U.S., men in the Mexican American 
group who were born in Mexico already had changed drinking 



288 



patterns from infrequent drinking of larger amounts to more 
frequent drinking of such amounts, which made their drinking 
similar to that of U.S.-born men. Among women, the change in 
drinking patterns described above only occurs among those born 
in the U.S. 

These findings provide a series of subsidies for prevention. 
The obvious primary target group for prevention should be men 
in their twenties and thirties, unmarried and in lower education 
and lower income groups. Liberal attitudes toward the ingestion 
of large amounts of alcohol and de facto drinking of large 
amounts per occasion should also be minimized, especially 
among Mexican Americans. Drinking in public places should 
also be targeted for prevention. This type of drinking is more 
visible, may lead to public disturbance more easily, and is done 
with less control than drinking at home, in bars or restaurants. 

The target group among women is that formed by women 
in their fifties, married, employed, more educated, born in the U.S 
and more acculturated to U.S. society. Changing demographics, 
with an increase in the number of U.S.-born women and increas- 
ing entry of women into the work force, may lead to higher rates 
of drinking and alcohol problems. 

Community Studies for the 
Prevention of Alcohol-Related 
Problems Among Hispanics 

Long gone are the days when the response to alcohol problems 
in the community was based mostly on secondary prevention, 
i.e., the provision of treatment for individuals with alcohol prob- 
lems. Prevention efforts nowadays are substantially more sophis- 
ticated, having shifted from a focus on alcoholics, roughly 7% 
of the general population who have been identified as alcohol 
abusers /dependent (Helzer, et al., 1991), to all alcohol-related 
problems. Prevention strategies have also shifted from a narrow 
focus on increasing knowledge about alcohol problems in school- 
based populations to a multi-pronged approach which empha- 
sizes the need for community involvement and interventions at 



O 



289 






a variety of levels: education, price manipulation, taxation, con- 
trol in the number of alcohol outlets in the community, hours 
of sale, minimum drinking age, advertisement (Wittman, 1985; 
Bruun, et al, 1975; Holder and Stoil, 1988). These approaches 
have been suggested as suitable strategies for preventing alcohol 
problems in the population in general and among ethnic /racial 
groups such as Hispanics (Ames and Mora, 1988; Gilbert and 
Cervantes, 1987; Caetano, 1988). 

Unfortunately, however, prevention interventions directed at 
Hispanic communities still lag behind other prevention activities. 
The same can be said of prevention research directed at U.S. 
Hispanics. Thus, assessments of the effectiveness of interventions 
such as school-based education, raising the minimum drinking 
age, administrative revocation of driving licenses, beverage con- 
tainers with warning messages and others have all provided 
results which may not be applicable to Hispanics or other ethnic/ 
racial groups. For instance, administrative revocation of license 
only works if individuals are driving with licenses. If, as seems 
to be the case with adolescent Hispanics, they drive without 
license, such strategies cannot be adopted as a prevention 
approach or will be less effective than otherwise. Studies of price 
elasticity, per capita consumption and its relation to changes in 
alcohol availability have not been directed at minorities either. 

Ames and Mora (1988) were able to find nine prevention 
programs directed at Hispanics, most of which were education 
interventions directed at children and adolescents. All projects 
had made an effort to develop interventions that were culturally 
sensitive, having the family as their central theme, developing 
bilingual material, and one utilizing a "fotonovela" to dissemi- 
nate information. Some of these projects were also discussed by 
Austin and Gilbert (1989), who also noted the lack of systematic 
evaluations of these interventions. As a result of the scarcity of 
ethnic-specific prevention research directed at Hispanics, the few 
existing efforts at evaluation are reviewed over and over again. 
Thus, Gilbert and Cervantes (1987) identified Caetano's (1982) 
evaluation of the Winners Campaign in California as the only 
existing evaluation of a prevention project directed at Hispanics. 
Ames and Mora (1988) reached the same conclusion, and at the 



290 



time of this writing that statement is -still valid with regard to 
large community-based efforts. 

Caetano (1982) described the outcome of a mass media and 
community organization alcohol prevention effort directed at 
Hispanics living in selected communities in the East Bay of San 
Francisco. The interventions consisted of a media campaign and 
community efforts. The media campaign used television and 
radio spots especially developed for the prevention intervention. 
The community efforts involved small group discussions and 
the distribution of leaflets, a prevention newspaper, calendars, 
bumper-stickers and automobile decals. Outdoor posters were 
also used to disseminate campaign messages. The evaluation 
followed a quasi-experimental design with two experimental 
sites and one control. One of the experimental communities 
received media and community interventions; the second experi- p5 

mental site received media messages only. Data were collected in 
three general population surveys of the communities in question 
before, during and after the interventions. 

The evaluation objectives were to assess increases in commu- 
nity awareness of alcohol dangers, changes in attitudes toward 
alcohol consumption and changes in drinking behavior. Results 
failed to show consistent changes in most areas, with some areas 
(attitudes) showing inconsistent changes throughout the project 
time, and which were therefore difficult to evaluate. Exposure, 
recognition and recall of television and radio spots in Spanish 
could not be evaluated due to limitations of the evaluation pro- 
cess. For those spots aired in English, exposure, recall and recog- 
nition of television spots and campaign themes were low. In 
spite of its failure to promote changes in drinking behavior, the 
campaign had many innovative aspects. It was the first time that 
a mass media effort was especially designed to prevent alcohol 
problems, and broadcasting time was purchased so that televi- 
sion and radio messages could be aired at hours during which 
the target audiences would be reached. The design had limita- 
tions, but the choice of experimental and control communities, 
plus the before and after data collection efforts, created a power- 
ful methodology for evaluation. But perhaps the most important 
lesson to be learned from this evaluation is that well-designed 



291 



prevention research directed at Hispanic communities can be 
conducted. 

What are the reasons for this lack of prevention research 
directed at Hispanics at a time when epidemiological research 
and public health professionals have identified target groups 
with high prevalence of alcohol problems, a variety of prevention 
approaches that could be applied to Hispanic communities are 
available, and support has also been made available by federal 
agencies such as the National Institute on Alcohol Abuse? First, 
it seems important to separate demonstration programs from 
prevention research. These are independent enterprises, which 
require different skills and training for implementation. Nowa- 
days there seem to be many more demonstrations programs than 
research, and the reasons why this is so are complex. It seems, 
however, that most of the professionals involved in service provi- 
sion and demonstration programs lack the training to develop 
and implement sophisticated research designs necessary to eval- 
uate prevention interventions. 

The situation becomes particularly acute with regard to 
research among minorities. Methodological designs and data 
collection efforts require extra steps when research is conducted 
among ethnic minority groups. Sample design needs to take into 
account oversampling, to obtain enough numbers of respondents 
in ethnic /racial groups; data collection needs extra time; ques- 
tionnaires need to be appropriately translated in the group's 
language; and interviewers need to be bilingual and have ade- 
quate training to interview minorities. Ethnic /racial profession- 
als, who may be more inclined than others to conduct such 
research and overcome these additional difficulties, are under- 
represented among researchers in general as well as among those 
dedicated to prevention research. Non-ethnic /racial researchers 
either lack the interest to conduct research with ethnic groups 
or are intimidated by the lack of ethnic match between them- 
selves and their subjects. There seems to be an unspoken rule 
that in order to conduct research on ethnic groups one needs 
to be "ethnic/' too. Approaches to generate more prevention 
research in Hispanic communities include training of minority 
researchers and stimulating the transfer of knowledge between 
researchers and service providers. 



292 



S3 



Prevention, Cultural Sensitivity, 
and Competence 

Like all other ethnic groups in the U.S., Hispanics have a unique 
culture, rooted both in that of the Latin American countries from 
which they originate and in their experience of life in the U.S. 
This culture sets them apart from the rest of the population, and 
suggests a need for prevention interventions and research that 
is specifically directed at U.S. Hispanics. Recent times have seen 
this need for ethnic-specific approaches challenged both in the 
areas of treatment and prevention research. With regard to treat- 
ment, the discussion has focused on whether it is necessary to 
provide ethnic-specific programs, i.e., programs that cater only 
to members of a certain ethnic group, or whether any program 
will do, once minimal attention to client characteristics are ful- 
filled (Institute of Medicine, 1990). In the prevention field the 
need for cultural sensitivity seems more acute, and some of this 
need is inherent to the nature of prevention strategies. Many 
times such strategies are not directed at the individual but at 
the community. It is essential, then, to be aware of community 
"ways" to be effective. 

Prevention interventions directed at reducing alcohol 
demand through mass media campaigns are a good example of 
the need for cultural sensitivity. These messages need to be 
disseminated in the language of the ethnic group and at a level 
that will allow easy apprehension of message content. The con- 
tent of the messages needs to be culturally appropriate, and the 
media used must be ones that will guarantee penetrance of the 
message in the community. Recent information from an AIDS 
campaign in San Francisco indicates that among Hispanics, celeb- 
rities are seen as less credible sources of information than physi- 
cians, clinical personnel and people with AIDS. These issues as 
applied to Hispanics have been recently discussed by Johnson 
and Delgado (1989). 

However, the debate around the need for culturally sensitive 
interventions has yet to be framed in specific terms. A good first 
step in that direction will be to achieve agreement on what is 



293 



meant by cultural sensitivity. How "specific" or "different" do 
the interventions promoted among ethnic /racial population 
need to be from those promoted among the majority population? 
Full and accurate answers to this and other similar questions 
regarding a variety of prevention strategies can only be answered 
empirically, i.e., by conducting comparative studies of effective- 
ness across ethnic groups. The present lack of evidence should 
not be taken as proof that culturally sensitive or ethnic-specific 
interventions are not necessary or do not work. The lack of 
research results in addressing the effectiveness of these interven- 
tions is at par with that about prevention interventions in general. 
Only by funding culturally sensitive and ethnic-specific preven- 
tion efforts and by attaching to these efforts the requirement to 
conduct methodologically sound evaluation research will it be 
possible to answer the questions about effectiveness of preven- 
tion strategies among minorities. In spite of its limitations, the 
design employed by the evaluation of the Winners campaign in 
California is a good example of the prevention research that 
can be conducted among minorities. This design included data 
collection with Hispanics selected at random from the communi- 
ties receiving the intervention and from the control community. 
These individuals were interviewed with standardized question- 
naires by trained interviewers before, during and after the pre- 
vention intervention was implemented. 

In the meantime, lacking information on the effectiveness of 
interventions, the best guess seems to be that some degree of 
cultural sensitivity is necessary, and the more sensitive the inter- 
vention is the more specific it will also be. The impact of cultural 
sensitivity on effectiveness may also vary from strategy to strat- 
egy. In the case of mass media campaigns it would probably 
be larger than in the case of price manipulation. Mass media 
campaigns need to pay attention to a series of aspects of commu- 
nication (vehicle, language, etc.) that are not present in a strategy 
such as price increases. In this latter case, interventions are usu- 
ally implemented though legislative action and are directed at 
more than one community, knowledge of local mores and cus- 
toms is not so necessary as assurance of population understand- 
ing of the reasons for such action. 



294 



Culturally sensitive or specific prevention interventions can 
only be developed, implemented and evaluated by researchers 
who are culturally sensitive and competent to work in ethnic/ 
racial communities. Cultural sensitivity has been defined as 
"awareness of the nuances of one's own and other cultures" 
(Orlandi, et al., 1992). Cultural competence is present when 
researchers have academic and interpersonal skills which allow 
them to appreciate and understand cultural differences and simi- 
larities across cultural groups. There should also be a willingness 
to conduct research work that is supported by "community- 
based values, traditions and customs, and to work with knowl- 
edgeable persons of and from the community in developing 
focused interventions, communications and other support" 
(Orlandi, et al., 1992). These characteristics can and should be 
developed by researchers independent of their ethnic /racial sta- 
tus, so that no ethnic match between researchers and community 
is necessary for the development and implementation of effective 
prevention interventions and evaluation. 



Disseminating Research Findings 

There has been considerable discussion of the barriers in dissemi- 
nating research findings to advance treatment and prevention 
interventions in the community. The separation between 
research and treatment (Kalb and Propper, 1976; Johns, 1988; 
Ogborne, 1988), the success and failure of community action 
projects (Giesbrecht, et al, 1990), the evaluation of prevention 
strategies in the community (Goodstadt, 1990), the dissemination 
of alcohol knowledge with educational purposes (Newman, 
unknown), and means to increase the exchange of information 
among prevention researchers and the community (Giesbrecht, 
et al., 1990) have been discussed in the literature. 

This literature suggests that the key aspect in disseminating 
results of prevention research is creating effective reciprocal com- 
munication between researchers and community agencies, com- 
munity leaders and others interested in prevention intervention 
(e.g., community developers, planners, activists, grass-root 
groups). Recently, a group of prevention researchers (see Gies- 



■ 



295 



:-. 



brecht, et al., 1990) proposed a model of communication that 
addresses the exchange of general information about prevention 
and the dissemination of findings that are specific to certain 
projects in the community. They also proposed a series of specific 
recommendations to enhance communication, which in sum- 
mary are: 

• Identify interested individuals, engage these individuals 
in all stages of the project, provide feedback, develop 
empathy and respect for these individuals. 

• Be available to community groups to discuss prevention 
findings. 

• Listen to community experiences and needs in design- 
ing research. 

• Spell out the implications of research, describing in the 
final report how research findings can be applied in the 
community. 

• Document the process of project development, enroll in 
training on how to respond to media, and be willing to 
reinterpret research findings to non-researchers and make 
recommendations . 

• Actively promote successful interventions and produce 
reports suitable for dissemination of knowledge to non- 
researchers. 

These well-thought-out recommendations should be applica- 
ble to the dissemination of prevention research findings in His- 
panic communities as well. The need to identify key players 
and key community organizations, as well as the need to create 
effective communication channels with the community remain 
the same. Some particularities applicable to Hispanic communi- 
ties, however, may exist. The community leaders or the commu- 
nity organizations involved in the process may change. Thus, 
the Catholic church or certain ethnic organizations may play 
a more important role in Hispanic communities than in other 
communities. Language barriers may be more of a problem in 
Hispanic communities, and research reports produced in English 
may also have to appear in Spanish. 

Dissemination of research knowledge should be based on a 
flow of information between researchers and the community. 



296 






Researchers should listen to community needs and community 
plans for action if those exist, and at the same time provide 
information that can be used in new areas of community action. 
For example, Hispanic and other ethnic /racial communities have 
been the target of special advertisement efforts by the alcohol 
industry (Maxwell and Jacobson, 1989), and guidelines for citizen 
action to control such advertisements have been published (e.g., 
McMahon and Taylor, 1990). Providing information to Hispanic 
communities about prevention efforts that will respond to partic- 
ular problems such as advertisement targeting is therefore part 
of an effective communication flow. 

The development of guidelines for describing community 
planning for the prevention of alcohol problems is an effective 
way to communicate prevention research findings. A number 
of such guidelines exist, focusing on prevention strategies for 
community groups (Minister of Health-Ontario, 1988), college 
drinking (Upcraft and Welty, 1990), prevention among youth 
(NIAAA, 1991a; Oyemade and Brandon-Monye, 1990; Goplerud, 
1991), women (NIAAA, 1991b), alcohol control strategies (Witt- 
man and Shane, 1988) and control of alcohol billboard advertising 
(McMahon and Taylor, 1990). Suggestions regarding the basic 
format for such guidelines have also been put forward (Gies- 
brecht, et al., 1990). Unfortunately, none of these guidelines 
addressed alcohol prevention in Hispanic communities. McMa- 
hon and Taylor's (1990) handbook on strategies to control adver- 
tising emphasizes actions by ethnic /racial communities, provid- 
ing special information about billboards in Black and Hispanic 
communities as well as information about drinking and minorit- 
ies. Most of the strategies proposed in these guidelines should 
work well with Hispanics, but a resource guide in English and 
Spanish especially directed to Hispanics would perhaps have a 
higher penetrance and effectiveness than these general publica- 
tions. 



Conclusions 

Hispanics constitute an important ethnic minority group in the 
U.S. Their presence in the country goes back almost 500 years. 



297 



They have a characteristic history in the U.S., marked by histori- 
cal events as varied as the colonization of the American West, 
political events in Cuba, the special political relationship between 
the U.S. and Puerto Rico, and continuous immigration. Recent 
epidemiological research has identified Hispanics as a group at 
high risk for developing alcohol problems. Such research has 
also identified subgroups of Hispanics who are at special risk 
for developing alcohol problems as well as particular problems 
which have a high prevalence in this group. 

These epidemiological findings suggest that Hispanics are a 
target group for prevention interventions. Yet, little systematic 
information on prevention programs directed at Hispanics and 
on the effectiveness of the existing interventions is available in 
the literature. Questions related to the need and value of "cultural 

£ sensitivity" in developing prevention interventions among His- 

panics can only be answered in relation to the strategy under 

I v consideration: The relationship between effectiveness and cul- 

tural sensitivity is bound to vary from intervention to interven- 
tion. It will probably be stronger in those strategies directed at 
decreasing alcohol demand through education, and weaker in 
those strategies based on decreasing alcohol availability such 
as price manipulation through taxation. The lack of prevention 
evaluation research directed at Hispanics does not seem to be 
due to lack of interest from funding sources. One of the main 
reasons for the dearth of research seems to be the lack of Hispanic 
professionals with expertise in conducting such research. It is 
therefore important not only to maintain the existing funding 
opportunities for prevention research, but also to step up efforts 
to attract and train Hispanic professionals in prevention research. 

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End Note 

1. The scale used to measure acculturation has been described 
in detail by Caetano. Briefly, the scale was built with twelve 
items assessing daily use and ability to speak, read and write 
English and Spanish; preference for media in English or Span- 
ish; ethnicity of the people respondents interacted with in 
their church, parties, and neighborhood now and when grow- 
ing up, as well as questions about values thought to be charac- 
teristic of the Hispanic way of life. 






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303 



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13 

Alcohol Abuse Prevention 
Research in the Hispanic 

Community 

Richard C. Cervantes and Isabel Garcia 



■ 

Author's Note: The author would like to thank all clerical and 
support staff at the Los Angeles County — University of Southern 
California Medical Center Child /Adolescent Outpatient Psychi- 
atric Clinic for their assistance in the preparation of this chapter. 
Special thanks is extended to Maxine Brown, who provided 
critical review of the manuscript. 

Introduction 

Although there are many differences in the behavioral norms 
and values among Hispanic Americans of different nationalities, 
different generations and different socioeconomic groups, certain 
values, beliefs and customs are maintained within this popula- 
tion. It is this set of commonly held values, beliefs, and customs 
that forms Hispanic culture. Variations in drinking practices 
between racial and ethnic groups reflect cultural differences in 
the values, beliefs and customs ascribed to alcohol by different 
groups. The intent of this chapter is to discuss the impact of 
Hispanic cultural factors on conducting community-based alco- 
hol prevention research. 



305 



















u 










' . 


'• 




1 















Culture, Family, and the 
Community 

Researchers and mental health professionals agree the concept of 
family lies at the heart of what is considered Hispanic "culture." 
Family rules which are endorsed by "the traditional Mexican 
family" were identified by several investigators some years ago 
(Montiel, 1973; Murillo, 1971; Romano, 1968). As described by 
these researchers, such cultural family rules appear to have been 
functional in securing the survival of large, traditional, lower 
class agrarian Mexican family systems. Such family systems 
emphasized family unity and a cooperative division of labor. A 
traditional family system offered protection in exchange for fam- 
ily loyalty. It emphasized family harmony and cooperation while 
discouraging individualism, competition, confrontation, and the 
open expression of anger. In this hierarchical system, family 
tasks and roles were divided by age and gender, with elders 
holding positions of authority and influence while children were 
obligated to obey elders under all circumstances. Males were 
encouraged to be macho, to express family pride, dominance, 
authoritarianism, and discipline, whereas females were encour- 
aged to be senoritas/senoras, to care for children, serve male needs, 
and show deference toward males while also expecting protec- 
tion from them (Carrillo, 1982; Falicov, 1982). More recently, 
specific changes within the traditional Hispanic family system 
have been described within a life-events change model (Padilla, 
Cervantes, Maldonado and Garcia, 1988). The traditional His- 
panic family constellation has given way to various economic and 
acculturative demands. Increased demands for change within the 
family system have been shown to adversely affect individual 
mental health functioning (Cervantes, Padilla and Salgado de 
Snyder, 1991). 

While generalized descriptions tend to capture the "flavor" 
of traditional Hispanic family values and normative rules, one 
must remember that the traditional Hispanic family is an abstrac- 
tion, an exaggerated and therefore inaccurate version of what 
various Mexican American, Puerto Rican, Cuban, and Central 



306 



' 



American families believe and practice today. Falicov (1982) has 
noted, in this regard, that broad generalizations such as these 
do not do justice to regional, generational, social class and other 
variations in family lifestyles observable across Hispanic fami- 
lies today. 

Even within a given Mexican American family system, strik- 
ing contrasts are often evident. One family member may identify 
strongly with these traditional family values, thus being highly 
motivated to comply with these cultural rules. By contrast, 
another family member who disagrees strongly may be highly 
motivated to actively oppose compliance with many of these 
cultural normative rules. Consequently, sibling or generational 
family coalitions may emerge, partitioning the family unit into 
factional groups (Goldenberg and Goldenberg, 1980). Children 
may strongly oppose the traditional cultural rules espoused by 
parents, and some immigrant parents may not fully understand 
the strong socialization influences affecting school-age children 
in the United States. Whereas traditional rules and standards for 
behavior have helped Mexican family systems maintain cultural 
identity, today, when a family member expresses a strict adher- 
ence to these rules that are out of context with majority culture 
demands, this strict adherence is likely to create stress for other 
family members (Cervantes and Castro, 1985). 

Currently, most Hispanic family systems function as sources 
of identity, self-worth ,and social support for their members by 
emphasizing familism, a family orientation that encourages fam- 
ily unity, the fostering of strong emotional ties between family 
members, and strong reciprocal kinship obligations (Bengston, 
1976; Grebler, Moore and Guzman, 1970; Nail and Speilberg, 
1967; Sotomayor, 1982; Vega, Hough, and Romero, 1983). Strong 
familism may help individual family members cope with social 
pressures that originate outside the family (Hoppe and Heller, 
1975), including peer pressure. 

Differences in the importance placed on family values can 
also vary. An isolated Mexican immigrant accustomed to receiv- 
ing frequent emotional, tangible and informational support from 
a large, closely knit family system will likely experience distress 
during a period of isolation from that family system (Melville, 



307 









1978). Another immigrant seeking emancipation from such fam- 
ily closeness and perceived intrusiveness may find the isolation 
of a new environment much less distressing (Keefe, Padilla, and 
Carlos, 1979). 

Studies of the help-seeking behavior of Mexican Americans 
both within and outside the extended family system report a 
process of differential help seeking by generational level. These 
have important implications for prevention researchers. First 
generation Mexican immigrants tend to have smaller extended 
family networks that the immigrant consults sparingly. By con- 
trast, second and third generation Mexican Americans tend to 
have larger extended family networks (Keefe, 1980). While hav- 
ing larger, more diverse family networks, second and third gener- 
ation Mexican Americans also have other support resources: 
friends, neighbors, clergy, and community institutions, thus hav- 
ing more of a choice in where to turn during times of need 
(Keefe, Padilla, and Carlos, 1979; Griffith and Villavicencio, 1984). 
Escobar and Randolph (1982) have distinguished between open 
family networks that are composed of many loose or weak con- 
nections and closed family networks that are composed of a few 
strong connections. They assert that traditional Hispanic families 
have maintained closed family networks although the process 
of acculturation has eroded the traditional family structure, 
including the strength of these family bonds. Weakening of fam- 
ily bonds has been associated with increased risk of alcohol and 
other substance use in youth. 

As an example, Santisteban and Szapocznik (1982) found 
that Cuban families at greater risk for drug abuse include a son 
who is ashamed of and rejects his culture of origin. These youths 
strive to become Americanized while the mother is described as 
traditional in her cultural beliefs and shows neurotic patterns of 
behavior including the abuse of sedatives or tranquilizers. Such 
families become fragmented by many family conflicts, both cul- 
tural and non-cultural, and tend to consist of an overly involved 
mother ,and a father who is distant, absent, and provides incon- 
sistent punishment. These investigators have concluded that the 
most adaptive survival strategy for various Hispanic families 
faced with intergenerational acculturative stressors involves 



308 






• 



adjusting to the prevailing environmental milieu. Members of 
families needing to survive in a monocultural environment could 
avoid maladjustment by developing monocultural skills congru- 
ent with that environment, whereas those families living in bicul- 
tural environments would do well to develop bicultural skills 
congruent with their culture of origin and with the demands of 
the host environment. In other words, according to Santisteban 
and Szapocznik (1982), individuals living in bicultural environ- 
ments tend to become maladjusted when they remain monocul- 
tural, although the relationship between acculturation and psy- 
chological impairment is admittedly a complex one (Griffith, 
1983). 

To summarize, strong family values and customs have tradi- 
tionally characterized Hispanic culture. Research has only 
recently shed some light on the impact of social, economic, and pi 

acculturative demands on Hispanic families residing in the 
United States. Alcohol prevention research must attend to the 
complexities of Hispanic families and the role of acculturation 
demands that may pose special risks for Hispanic family mem- 
bers. Much research on such family-related risk factors is needed 
so that alcohol prevention studies may best target these fam- 
ily variables. 

Culture and Religion 

Religion has historically played an important role in the lives of 
Hispanic American families, with most Hispanics being Catholic. 
Family life cycle events in traditional Hispanic families are usu- 
ally centered around the Catholic church and include traditions/ 
rituals such as the baptism, first communion, confirmation, 
quinceanera (female's 15th birthday celebration), marriage, and 
death. Suffering and self-sacrifice are important and strong reli- 
gious values that are transmitted to Hispanic families through 
the Catholic church. Maintaining an attitude of acceptance 
toward one's suffering is perceived as virtuous behavior and 
becomes part of the predetermination philosophy taken by many 
Hispanics (e.g., "what is meant to be will be"). Self-sacrifice is 
also thought to be directly related to spiritual rewards in the 



309 



afterlife (going to heaven; having eternal life). Such beliefs among 
traditional Hispanics are strong and can affect how illnesses, 
behavior disorders (including alcoholism), and personal short- 
comings are dealt with by family and friends. In a discussion of 
alcohol treatment for Mexican Americans, Gilbert and Cervantes 
(1986) conclude that some families may endure male alcohol 
abuse beyond the extent to which the alcoholic's health and 
occupation are adversely affected. Male alcohol abuse may only 
be defined as problematic by the family when nuclear and 
extended family relationships are severely impacted. Prayer is 
often seen as an important solution to such family problems. 

The Catholic church has historically played a central role in 
the lives of Hispanics. Not only has it provided spiritual and 
moral guidance, but it has been an important source of social 
support. Interestingly, however, the social support needs of His- 
panics are increasingly not being met by the Catholic church. 
This may be due to its large size and its impersonal nature. 
Consequently, many immigrant Hispanics are now turning to 
smaller Evangelical churches through which the social support 
needs of this population are more likely to be met. Developing 
appropriate and effective prevention and intervention programs 
for Hispanics should consider the factors mentioned above. Spe- 
cifically, the role of the family and the Catholic church in shaping 
the values of Hispanics needs to be considered and incorporated 
into the development of prevention programs and the design of 
intervention strategies. By taking this approach, the integrity of 
this population's cultural identity is likely to be maintained and/ 
or enhanced. This, in turn, is likely to improve a program's 
effectiveness. 



Brief Description of Alcohol Use 

In 1985, approximately 87% of high school seniors reported to 
have used alcohol in the past year, and approximately 69% were 
currently using alcohol (Adams, 1986). These rates illustrate the 
prevalence of alcohol use in late adolescence, yet alcohol use can 
start early in life. Research by the National Institute on Drug 
Abuse has shown that 8.4% of United States children start to 



310 






use alcohol as early as the sixth grade (Johnston, O'Malley, and 
Beckman, 1987). 

Membership in different ethnocultural groups is an impor- 
tant factor that differentiates patterns of alcohol and other drug 
abuse in the United States population. For instance, a 1975 
National Survey of Adolescent Drinking Patterns found that 
Anglo American adolescents are the heaviest drinkers (75 per- 
cent), followed by American Indians (73 percent), "Spanish 
Americans" (68 percent), and African Americans (59 percent) 
(reported in Office for Substance Abuse Prevention, 1990). Pat- 
terns of different drugs used also varied by ethnocultural groups. 

The 1986 National Institute on Drug Abuse (NIDA) House- 
hold Survey (1987) reports that although the use of alcohol and 
other drugs by adolescent African American and Hispanic 
females is lower than that of adolescent Anglo American females, pj 

rates of cocaine use are similar for Anglo and Hispanic females. 
Additionally, NIDA reports that lifetime prevalence rates of 
inhalants was slightly higher for Anglo females than for either 
Hispanic or African American adolescent females. 

Drug use patterns also differ between different Hispanic sub- 
groups. According to the 1987 Hispanic Health and Nutrition 
Examination Survey (H-HANES, 1987), 31 percent of Mexican 
Americans aged 12 to 17 reported some lifetime use of marijuana 
compared to 26 percent of Puerto Rican youth of similar age. Of 
all Cuban Americans aged 12 to 24, 21 percent reported having 
used marijuana at some time in their lives. Specific differences 
in alcohol use patterns among Hispanics by subgroup and gender 
were found by Caetano (1985). For example, Mexican American 
females had an alcohol abstention rate of 71%, followed by Cuban 
females (48%), and Puerto Rican females (45%). Less frequent 
and light drinking (i.e., drinking one to three times per month 
and never having more than five drinks at one sitting) is more 
prevalent among Puerto Rican (41%) and Cuban males (41%). 
Mexican males (12%) and third generation, or more, males (14%) 
are found to engage in frequent low maximum drinking (i.e., 
drinks more than once a week but never takes more than five 
drinks per sitting) more often than Mexican females. United 
States-born Mexican American females (26%) are more likely to 



311 



engage in frequent and high maximum drinking (i.e., respondent 
drinks once a week or more and has five or more drinks per 
sitting when compared with other subgroups of Hispanic 
females). Mexican males (23%) also were found to have high 
rates of frequent high maximum drinking, followed by the 
United States-born second generation males. Lastly, United 
States-born Hispanic males (35%) and Mexican-born males (19%) 
are just as likely to engage in frequent heavy drinking (i.e., 
respondent drinks five or more drinks per sitting once a week 
or more often). Overall, the current body of epidemiological 
research shows that males of Mexican heritage are at risk for 
developing problems associated with excessive and frequent 
alcohol abuse. 

Although adult Mexican American males engage in heavier 
drinking behavior than Anglo American males, Mexican Ameri- 
can adolescents and youth engage in less drinking behavior than 
Anglo American adolescents and youth (Caetano, 1987). It fol- 
lows, then, that there must be a set of factors that interact in 
leading to the problem of alcohol abuse in adult Mexican Ameri- 
cans. First, it is generally permissible for adult males to drink 
heavily. As mentioned previously, some Hispanic families may 
tolerate heavy problem drinking beyond the point where it cre- 
ates health and occupational difficulties. Secondly, adult male 
support systems can encourage drinking to facilitate social inter- 
actions that serve as informal information and support networks. 
"Machismo" (i.e., the pride a man feels toward his own masculin- 
ity) may also play a role in male drinking behavior. Strong group 
pressure for adult Hispanic males to demonstrate their masculin- 
ity by engaging in alcohol consumption has been found (Ames 
and Mora, 1988; Cervantes, Gilbert, Salgado de Snyder, and Padi- 
11a, 1990). 

Besides those factors outlined above, it is possible that accul- 
turation stressors experienced in some Hispanic households lead 
to the use of familiar coping techniques for reduction of tension, 
including alcohol use. For Mexican American males this may be 
manifested in turning to a male support group where drinking is 
considered normative behavior. Such stressors include language 
barriers, chronic unemployment, and unexpected shifts in gender 
role behaviors. 



312 



s, 



Previous Prevention Efforts 

Given the risk for alcohol abuse among some Hispanic sub- 
groups, and the number of factors that interact in contributing 
to alcohol abuse, prevention interventions are best designed 
when they target multiple risk and resiliency factors. The "Gana- 
dores" program is one such attempt, through which a culturally 
sensitive mass media and community organization alcohol pre- 
vention program was implemented with a sample of Spanish- 
speaking persons in three California communities (Ames and 
Mora, 1988; Caetano, 1982). In this program, two communities 
were exposed to the media campaigns; one site included commu- 
nity organizing in its intervention. The third site served as a 
control where no interventions were implemented. The evalua- 
tion results of the program indicated no changes in drinking 
behavior, attitudes, and alcohol problems in either the overall 
sample or the Spanish-speaking subsample (Ames and Mora, 
1988; Caetano, 1982). Reasons for the lack of success may include 
duration of the intervention, lack of reading skills of the target 
community, and insufficient inclusion of target families, schools, 
and churches in the design of the program. 

Another program through which interventions were aimed 
at the school environment, as well as youth at risk for delinquent 
behavior, resulted in a small reduction in delinquent behavior 
and misconduct (Gottfredson, 1986). Gottfredson reports that 
students in the participating schools were suspended less often, 
reported fewer punishing experiences in school, and reported 
less involvement in delinquent and drug-related activities. It 
appears that in this program the environmental interventions 
promoted a sense of belonging and attachment to the school that 
played a role in decreasing delinquent behaviors. Similar results 
have been found in a prevention program targeted at 15 commu- 
nities that make up the Kansas City metropolitan area. This 
program includes mass media programming, a school-based 
education program for youth, parent education and organization, 
community organization, and health policy components. The 
results of this program indicate that prevalence rates for drug 
abuse were reduced and that the program is effective for both 



313 



high-risk and low-risk adolescents (Anderson, et al., 1990; Pentz, 
et al., 1989). The multif actor approach of these programs ensures 
that the problem of drug abuse is addressed at various levels, 
and includes each institution that has contact with youth. 

Specific Alcohol Prevention Issues 
for Hispanics 

Cultural sensitivity is important in the development of preven- 
tion and intervention programs targeted at culturally diverse 
populations. Specifically, it is necessary to understand how mem- 
bership in given cultural groups influences attitudes and behav- 
iors. According to Gibbs and Huang (1989), ethnicity affects how 
mental health and illness are defined, it affects how symptoms 
are manifested, it determines help-seeking patterns, it is a factor 
that shapes response to treatment, and ethnicity likely influences 
the receptiveness to prevention programs. It is, therefore, impor- 
tant for researchers to understand the culture of the population 
targeted. In developing Hispanic prevention projects, care must 
be taken to understand the cultural nuances of a given commu- 
nity in terms of language, generational status of the target group, 
and level of acculturation. Prevention programs or prevention 
messages that fail to take these variables into account will likely 
result in small changes regarding expected outcomes. 

In addition to developing prevention research strategies that 
are culturally and linguistically relevant for the target commu- 
nity, building a sense of trust and mutual collaboration within 
the Hispanic community is essential. Historically, researchers 
have been viewed as outsiders whose only interests have been 
in the furthering of academic careers. Further, many community 
members express resentment at study findings that portray the 
Hispanic community as having many social, economic and health 
problems. Results that describe ethnic communities as such may 
only worsen long-held stereotypes without addressing the many 
strengths (e.g., resiliency factors) inherent in these communities. 
Apart from this, many researchers have ignored the need for 
community members to be involved in the various phases of 
prevention research, including the planning and implementation 



314 






of these projects. Historically, the lack of developing such com- 
munity linkages has resulted in a basic mistrust of university- 
based researchers desiring to conduct research in Hispanic com- 
munities. 

Community Connections 

Successful community-based prevention research efforts for His- 
panics require establishment of key connections in the target 
community. Prevention research studies are likely to be success- 
ful if the researcher can connect with various institutions that 
serve Hispanic families, including schools, the church, and health 
service agencies. To the extent that linkages can be developed 
with such institutions, there will be greater acceptance and ' 'buy- 
in" by the Hispanic community. Such linkages have proven 
successful in community-based alcohol and mental health 
research by this author (Cervantes, Gilbert, Salgado de Snyder, 
Padilla, 1990; Cervantes, Padilla, and Salgado de Snyder, 1991) 
where local churches and adult education centers provided an 
entree to the target samples. If such institutions can serve as co- 
sponsors of a prevention study, many barriers related to mistrust 
can be overcome. 

Connecting with the target community must also involve a 
process by which community members are engaged in the plan- 
ning of prevention studies. Focus group meetings, key informant 
interviews and community forums may provide an important 
opportunity for Hispanic community representatives to give 
input into the actual design of a project such that a prevention 
trial can successfully be accomplished. This process can 
strengthen the researcher /community relationship, thereby 
ensuring a successful research effort, especially if a liaison person 
or persons can be trained and become part of the actual research 
team. Such community liaisons can actually serve to bridge the 
research project with the community, as well as overcome any 
additional feelings of mistrust of suspiciousness regarding the 
research team. This may be a very critical component to the 
research where the research director or research team members 
are not Hispanic. Of course scientific rigor will only be main- 



315 



tained when the researcher makes final decisions regarding spe- 
cific design and methodologic considerations. 

A successful connection between researcher and the commu- 
nity will benefit from a process of open communication where 
information exchange occurs on a regular basis. 

Conclusions 

Planning and implementing alcohol prevention research in His- 
panic communities must consider a variety of factors that will 
affect the research process. An understanding of the heterogene- 
ity of the culture, the values placed on family and religion, and 
variations in acculturation must be incorporated into the design 
of such studies. Studies that recognize the importance of commu- 
nity risk and resiliency factors, particularly for Hispanic youth, 
are greatly needed in furthering our understanding of the pro- 
cesses that result in excessive alcohol use. These studies are 
greatly facilitated through a process that involves the community 
as an active participant in the research, as opposed to studies 
which fail to recognize community involvement as a legitimate 
and important step in the research process. 

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14 

Issues in Hispanic Alcohol 

Prevention Research: 

Comments from 

a Clinical-Community 

Orientation 

Judith A. Arroyo 



Introduction 

This paper will first comment on controversies about the shortage 
of prevention research in ethnic and racial communities raised 
during the proceedings of the ' 'Working group on alcohol pre- 
vention research in ethnic communities ,, from the perspective 
of a clinically trained, community-oriented academician. The 
ideas expressed in this paper are synthesized from a variety of 
sources: (1) the other papers delivered at the working group 
and published in this volume, (2) the greater Hispanic alcohol 
literature, (3) the community psychology and ethnic /racial men- 
tal health literatures, (4) the comments of the working group 
participants, and (5) the experiences and thoughts of the author 



The work reported in this article was supported in part by Grant Number T15- 
SPO7540 from the Center for Substance Abuse Prevention. 



321 



L. 



about conducting research on the influence of acculturation on 
Hispanic use of alcohol and the prevention thereof. It will provide 
a framework to conceptualize the various approaches to psycho- 
social research in ethnically and racially diverse communities 
and discuss their relevance to the obstacles the working group 
noted to conducting prevention research in the Hispanic popula- 
tion. Finally, it will argue that a model of acculturation, one that 
posits that adaptation to the Hispanic and Anglo cultures are 
independent of each other, might shed light on alcohol-related 
risk and resiliency factors in the Hispanic population. 

Members of the working group commented on the apparent 
paucity of research focused on the prevention of Hispanic alcohol 
abuse. One recent review (Ames and Mora, 1988) found only one 
published study and eight unpublished ones. Since prevention 
t programs are operating in the Hispanic community, why are 

reports so rare? The working group identified numerous contrib- 
uting factors: (1) The pressing need for treatment in the Hispanic 
community may overshadow reports on prevention efforts; (2) 
obstacles to obtaining funding for, conducting rigorous evalua- 
tion of, and publishing the results of prevention programs are too 
great for grassroots organizations; (3) the shortage of culturally 
competent researchers; and (4) communities of color are highly 
suspicious of academic researchers and make access to subjects 
difficult for researchers. 

While leaders of the Hispanic community are interested in 
preventing alcohol-related problems, the need for treatment 
often takes precedence over prevention. When prevention efforts 
are undertaken at a community level, program staff is often 
not conversant in nor condoning of the sophisticated techniques 
necessary for rigorous evaluation (i.e., design and statistics, ran- 
dom assignment, no intervention controls, etc.). Finally, anyone 
who has attempted to apply for funds without a credible list of 
scholarly publications in the area can attest to the obstacles in 
competing for grants. For some, it might appear that they cannot 
get a grant without publications but cannot get the publications 
without the data generated from grants. 

Many participants in the working group felt that the lack 
of prevention research was related to the critical shortage of 



322 



culturally competent researchers from either the Hispanic or 
non-Hispanic cultures. Training large numbers of Hispanics as 
a solution to the scarcity of prevention research assumes they 
will all apply their advanced degrees both in their communities 
of origin and by undertaking prevention research. Hispanics 
with post-graduate degrees are in high demand. Prevention 
research has to compete with careers in teaching, treatment, 
community action, and business. The working group endorsed 
the need to identify, mentor, and graduate interested Hispanics 
and other persons of color to promote research in communities 
of color. Yet, we generally agreed that this could not and should 
not be the ultimate solution to the shortage of culturally compe- 
tent prevention research. Relying solely on Hispanics to conduct 
prevention research would contribute to the sentiments 
expressed by the working group that community-based research 
is restricted to people of color and contribute to hesitation by 
non-Hispanic Whites to engage in such work. r * 

Instead of relinquishing responsibility for conducting pre- 
vention research to those whose ethnicity matches that of the 
target community, we need to focus on training all researchers 
to be competent to conduct culturally sensitive work in diverse 
populations. The American Psychological Association's Guide- 
lines for Providers of Psychological Services to Ethnic, Linguistic, and 
Culturally Diverse Populations (1990) could serve as a model for 
developing a similar set of research guidelines. As Moran (1992) 
noted, cultural competence can become part of the basic training 
of researchers in graduate programs. Unfortunately, there are 
few graduate programs that are mandating cultural competence 
training as part of the core curriculum (Porsche-Burke, 1991). 

History of Research with Diverse 
Populations 

The working group debated what constitutes culturally compe- 
tent research and the relationship this may or should have to 
the obstacles investigators face when conducting research in 
communities of color. There has been considerable attention in 
both the minority mental health and community psychology 



323 



literatures to the shortcomings and strengths of research with 
diverse populations. A brief review of this history may explain 
why there is so much resistance by culturally and racially diverse 
communities to allow further research to be conducted. 



Failure to Address Cultural Diversity 

One of the most basic research errors is to fail to take ethnic or 
racial background into account when results are to be applied to 
culturally diverse groups. Caetano (1990) concluded that, while 
empirically rigorous survey research conducted in the 1960s 
expanded our general understanding of alcohol use, few Hispan- 
ics were included and they were never the focus of analyses. "No 
detailed descriptions nor major conceptual models regarding 
drinking by members of this ethnic group were developed/' (p. 
1231). Similarly, Gilbert (1992) noted the multitude of "white 
only or White dominated" school-based prevention programs. 
Thus, a major limitation of alcohol prevention and treatment 
research has been that too much of the empirical work has 
focused on non-Hispanic Whites, treating the problem as a 
generic concept devoid of cultural context (Caste, 1981). When 
researchers or research consumers are not experienced with cul- 
tural variation, they tend to interpret results of work conducted 
with non-Hispanic Whites equally across ethnic groups. 

A related research flaw is the failure to report or directly 
address the ethnic /racial composition of samples. It is all too 
easy to neglect ethnic variability with Hispanics by describing 
subjects as "Caucasian" because they are technically members 
of this racial category. Such reporting obscures critical informa- 
tion that influences design, measurement, interpretation, and 
application of the research. Interactions with colleagues who are 
ill at ease when they do not match their population's ethnic/ 
racial background or who ignore differences across ethnic groups 
suggest that they do not feel "culturally competent" to address 
issues of diversity. This highlights the problem of relying exclu- 
sively on persons of color to address the growing need for data 
on diverse populations. 



324 



Models of Psychosocial Research with 
Diverse Populations 

Other types of issues arise when ethnicity or race is incorporated 
into research. These are particularly relevant to the difficulties 
investigators have in gaining access to communities of color. 
Sue, Ito, and Bradshaw (1982) discuss three orientations to psy- 
chological research with diverse populations: (1) inferiority, (2) 
deficit, and (3) bicultural or multi-cultural models. The first two 
demonstrate the tendency to make pejorative comparisons 
between people of color and a // standard ,/ or control group. This 
practice is particularly biased when the current standard in much 
of psychological theory, measurement, and methodology is a 
White, middle-class, educated, youthful population (see Sears, 
1986). This is especially so when clinical research has demon- 
strated that psychologists' standard for psychological health and 
well-being is male as opposed to female (Broverman, et al., 1970), 
and Anglo American as opposed to Mexican American 
(Lopez, 1977). 

Cultural Inferiority Model. The inferiority model of cross- 
cultural research is predicated on comparing a diverse group 
to a "normative" standard. Psychosocial models developed for 
Western, first world, White, usually affluent groups are tested 
among groups that do not fit this description. The generalizability 
of psychological theories and research methods to diverse cul- 
tures has come into serious question (Benacourt and Lopez, 1993; 
Pepitone and Triandis, 1987). In light of our knowledge of the 
culturally biased and /or specific nature of most assessment tools, 
it is not surprising that diverse groups frequently score lower 
on the dimension of interest. What is particularly disturbing 
about this style of research is the interpretation of results so that 
the diverse group is judged to be inferior to the non-Hispanic 
White standard. Inferences have strayed so far as to imply that 
genetic inferiority accounts for results. A classic example of such 
a biased interpretation in the alcohol literature is the Fenna, et 
al. (1971) study which came to the controversial conclusion that 
Native Americans metabolized alcohol at a significantly slower 
rate than did non-Hispanic Whites. While these results have 



325 






since then been attributed to methodological flaws, researchers 
continue to seek biological weakness in people of color. Recently, 
there has been an effort to find differences between Hispanics 
and Whites on possible biomarkers for excessive alcohol con- 
sumption (LaGrange, et al., 1993). While such research may pro- 
vide useful information, the risk of interpreting results as indica- 
tive of biological inferiority is great. 

Cultural Deficiency Model. Cultural deficiency model 
research still compares diverse groups to non-Hispanic Whites. 
However, according to this model, any differences found are 
not attributed to some biological /genetic flaw but to social and 
cultural factors. Communities of color are seen as suffering the 
effects of societal prejudice and discrimination. Perhaps the most 
memorable research examples are found in the "culture of pov- 
erty" research of the 1960s, such as Tally's Corner (Liebow, 1967) 
and The Children of Sanchez (Lewis, 1961). Cultural deficiency 
interpretations might sound less derogatory than inferiority 
explanations; however, this may not be so for people of color who 
feel shamed when research reports reinforce cultural deficiency 
stereotypes (Moran, 1992). While no longer thought to be biologi- 
cally inferior, they find themselves doomed to live in a culture 
that is likely to damage their psychosocial development or well- 
being. The emphasis in the cultural deficiency model is on weak- 
nesses over strengths, competencies, and adaptive skills found 
within communities of color. 

The manner in which "machismo" is used to account for 
heavy, frequent drinking among Hispanic males often takes on 
cultural deficiency overtones. This is especially so when a cultur- 
ally sanctioned concept about appropriate male behavior is taken 
out of context, exaggerated, and used in an ethnocentric, stereo- 
typical fashion. Machismo and its relationship to alcohol prob- 
lems is seldom operationally defined and measured (Alcocer, 
1982; Caetano, 1990). The degree to which research finds that 
culturally defined gender roles and male prerogatives relate to 
alcohol problems may depend on the way in which terms like 
"macho" or "real men" are employed therein. Machismo has 
been defined as the culturally sanctioned manner in which a 
man expresses male or family pride, discipline, authoritarianism, 



326 



and dominance (Falicov, 1982). However, its usage has degener- 
ated in the vernacular to a stereotypical exaggeration of male 
aggressiveness, masculinity, sexism, etc., which is commonly 
used to describe non-Hispanic as well as Hispanic males (e.g., 
a real macho man). Thus, it is unclear what aspect of the male 
role subjects are referring to when they endorse items like "A 
real man can hold his liquor". (Caetano, 1990, p. 1233). 

Communities of color have had considerable experience with 
cultural inferiority and deficiency model research. This has led 
to a general distrust of researchers and impediments to their 
gaining access to subjects in diverse communities. Why should 
leaders help investigators whom they suspect might engage in 
exploitative research? Community leaders are hesitant to encour- 
age their constituents to give honestly and generously of their 
time to researchers who might behave in an opportunistic or 
cavalier fashion. Increasingly, community leaders are demand- 
ing a reciprocal partnership with the research team. Cervantes 
and Garcia (1992) and others in this volume (e.g., Beauvais, 
Moran, Gilbert, or Stubben) provide suggestions as to how to 
develop such a collaboration. Furthermore, leaders are demand- 
ing clear promises that the researchers will donate something of 
value in return for endorsing investigations. The working group 
discussed several examples of such payback: (1) hiring locals to 
staff programs, (2) renting offices within the target community, 
(3) mentoring aspiring researchers, (4) paying subjects and /or 
institutions for participation, (5) educating community members 
about the target problems and research, (6) reporting results 
back to the community in an understandable and usable fashion, 
and (7) leaving equipment (e.g., computers, audio and video 
equipment) in community schools or centers, etc. Granting agen- 
cies will need to work out mechanisms for addressing these 
issues. 

Bi/Multi-cultural Model. Sue, et al. (1982) proposed a bi/ 
multi-cultural approach that emphasized an understanding of 
the diverse group in their own terms. Whereas the previously 
discussed models highlight similarities and differences between 
groups, bi/ multi-cultural research explores the dynamic inter- 
play and interaction between diverse and United States Western- 



327 



based values. At times this may entail comparing Hispanics to 
non-Hispanic Whites when such contrasts are demanded by the 
hypotheses being tested or have valuable treatment or prevention 
implications. For example, Caetano (1992) points out that while 
Hispanic women are much more likely to abstain from alcohol 
than non-Hispanic Whites (46% v. 36%), frequent heavy drinkers 
are older among Hispanic than among non-Hispanic White 
women (50's v. 30's). However, the research community should 
come to realize that not all investigation demands comparison 
to some hypothetical normative standard. 

Alternative Perspectives on 
Alcohol Prevention Research EMIC 
Models 

t u There are other alternatives to imposing theory, design, and 

measurement developed for White populations onto communi- 
ties of color. Raising the etic-emic distinction made in cross- 
's 

cultural psychology is appropriate at this juncture (see Brislen, 
1993). The term etic applies to concepts and theories that are 
common across cultures. Much of psychological research and 
practice currently assumes that concepts rooted in Western, first 
world societies are etic and valid for diverse cultures. The alterna- 
tive is an emic viewpoint that seeks to understand culture-specific 
concepts. Emic research investigates how aspects of a culture 
influence behavior. Emic and bi/ multi-cultural research are simi- 
lar except that emic research avoids comparisons, whether 
implicit or explicit, with other groups. As far as an emic-oriented 
researcher can investigate from within that culture's perspective, 
it is possible to avoid imposing the biases associated with the 
culture of science (Beauvais, 1992). In contrast to the pejorative 
contrasts often set up in comparative work, emic research allows 
for exploration of how a culture might promote healthy behavior 
in its members. Alcohol prevention work has much to gain from 
research that can discover how culturally related variables con- 
tribute to both the vulnerability and the resilience of Hispanics. 
Viewing the concept of macho solely from the perspective 
of the Mexican or Mexican American culture allows us to inte- 



328 



grate rich ethnographic material not often cited in this context. 
An emic researcher might discover that the original cultural ideal 
of being "muy macho" or being a "real man" includes fulfilling 
responsibilities and obligations to his family, protecting and 
defending his family's interest, and serving as a good role model 
to his children (Panitz, et al., 1983). Rodriguez- Andrew, et al. 
(1988) found that Hispanic male "Access to and participation in 
drinking activities . . . does not go unaccompanied by a corres- 
ponding set of culturally prescribed duties." (p. 117). They cited 
evidence of the connection between a man's obligations to his 
family and his prerogative to drink and concluded that sanction- 
ing of male drinking could "stem from cultural concepts of 
reward and reinforcement for role obligations adequately dis- 
charged rather than from traditions of indulgent permissiveness" 
(p. 118). They speculated that adoption of this attitude may be 
associated with an increase in women's drinking once they enter 
the labor force. This may account for the relationship recently 
found between reporting drinking to reward hard work as a 
reason for drinking and heavy and frequent drinking for both 
Mexican American men and women (Golding, et al., 1992). 



Hispanic Heterogeneity 



How might research on Hispanics that does not compare them 
to non-Hispanic Whites promote effective prevention? An 
attempt to organize our knowledge of the relationship of accul- 
turation and gender roles to Hispanic drinking patterns will 
provide excellent examples of how to improve the state of the 
art in prevention research. First, such an orientation would force 
one to integrate the tremendous heterogeneity of the many cul- 
tural groups encompassed within the generic Hispanic label. 
Even the criterion employed to define an Hispanic group (e.g., 
national group, origin of ancestors, family of origin, or birthplace) 
has impact on findings (Caetano, 1986). Hispanic females from 
different national origins evidence variability in drinking pat- 
terns (Caetano, 1988a; Gilbert and Cervantes, 1986). Although 
rates of abstention and infrequent drinking are similar for Mexi- 



329 



can and Puerto Rican females (69% v. 62%), their rates of frequent 
high maximum and of frequent heavy drinking are very different 
(14% v. 5%) (Caetano, 1987). 

Regional, class, age, education and acculturation differences 
make it impossible to generalize even within a national origin 
group. There are regional differences in patterns of Mexican 
American alcohol use in Texas and California (Caetano, 1988b). 
While rates of female abstention are very similar, Mexican Ameri- 
can females in Texas have a higher rate of infrequent drinking 
than in California (29% v. 8%). Likewise, Calif ornian Chicanos 
have higher rates of frequent high maximum and frequent heavy 
drinking than their Texan counterparts (19% v. 4%). Emphasizing 
a thorough understanding of the target group over comparisons 
with non-Hispanic Whites would have considerable impact on 
improving prevention intervention and evaluation. 

Acculturation and Acculturative 
Stress 

Acculturation and the stresses associated with it have been impli- 
cated in Hispanic drinking (Gilbert and Cervantes, 1986). Accul- 
turation is a process that entails changes in culturally patterned 
values, beliefs, attitudes and behaviors that transpire when two 
cultural groups come in close contact. Gilbert (1991) noted several 
important trends in her recent analysis of acculturation and alco- 
hol use among Mexican American women. Mexican American 
females are very likely to be abstainers or very light drinkers. 
While they do not alter their pattern of abstinence or low fre- 
quency, low quantity drinking upon immigration, they show a 
linear change in drinking pattern across generations in the U.S. 
By the third generation they are drinking more like American 
than Mexican women. This suggests that perhaps some aspects 
of the traditional Mexican culture lower risk for alcohol-related 
problems among females and that either loss of these factors or 
increased interaction with the dominant culture increases risk. 
A recent analysis of the relationship between acculturation 
and mental health status yielded inconclusive results. This was 



330 






■-. 



attributed to problems with the models of and measurement of 
acculturation and the linkage between these and mental health 
outcomes (Rogler, et al, 1991). Similarly, Caetano (1990) posits 
that the parallel failure in the alcohol literature for acculturation 
to explain differences in alcohol use is due to a lack of sophisti- 
cated models of acculturation and its relationship to acculturative 
stress. He notes that the generally liberalizing effect of accultura- 
tion on drinking habits is influenced by sex, age, and birthplace 
and thus "cannot be seen just in terms of acculturative stresses ,/ 
(p. 1232). Underlying this conclusion is the unproven assumption 
that transition from one culture to another is inherently stressful, 
and that acculturation and acculturative stress are linearly related 
(Beauvais, 1992; Oetting and Beauvais, 1990). While early 
descriptions of the relation of Hispanic acculturative stress to 
alcohol use failed to define the concept clearly (Gilbert and 
Cervantes, 1986), more recent work has empirically investigated 
the stresses Hispanics encounter when acculturating to U.S. soci- 
ety (Cervantes, et al., 1990). One cannot assume that acculturative 
stress invariably accompanies an increase in the level of accultur- 
ation. Not all ethnic groups in the U.S. experienced incapacitating 
stress in the process of assimilating into the majority group. 



Limitations of Current Models and 
Measures of Acculturation 

Theories and accompanying measures of Hispanic acculturation 
are under considerable investigation, especially among Mexican 
Americans (Keefe and Padilla, 1987). These have included crude 
proxies for the concept such as language usage, birthplace, or 
number of generations in the United States as well as more 
refined measures such as uni-dimensional and multidimensional 
bipolar linear scales, semantic differentials, typologies, and two- 
culture matrix models. Organizing our knowledge of the influ- 
ence of acculturation on alcohol use patterns within a framework 
of the interaction between the United States and Hispanic cul- 
tures might help account for paradoxes in the Hispanic alcohol 



331 









literature. That is, perhaps there are ways to conceive of accultur- 
ation that can account for many acculturative options and still 
be consistent with the evidence about the influence of other 
factors such as sex, age, education, income, and birthplace on 
alcohol use. 

Caetano (1990) argued that we need to consider more com- 
plex models of acculturation such as Berry's (1990) ideas, which 
allow not only for stress and marginality but for integration and 
assimilation. Similar suggestions have been made in the Hispanic 
mental health literature. Rogler, et al. (1991) concluded that the 
dominant bipolar linear models of measuring acculturation con- 
strain a subject's responses to mutually exclusive, competitive 
choices between Hispanicism versus Americanism. They join 
others in arguing "for the need for separate measure of . . . cul- 
tural involvement" (Rogler, et al., 1991, p. 587). In the alcohol 
literature, Beauvais and colleagues (Beauvais, 1992; Oetting and 
Beauvais, 1990) have posited an orthogonal model of accultura- 
tion by which adherence to ethnic or traditional cultures (i.e., 
Hispanic and Native American) can vary independently of sub- 
scribing to the dominant non-Hispanic White culture. One can 
integrate these ideas into a framework that shows promise to 
be a sophisticated model of acculturation that is consistent with 
the results of research on patterns of Hispanic alcohol use. 

Berry (1990) conceptualized acculturation as a function of 
the responses an individual makes to two questions: (1) To what 
degree do I want to retain my culture of origin? and (2) To what 
degree do I want to interact with members of the society other 
than my own group? Oetting and Beauvais (1990) presented 
their subjects with a conceptually related set of questions: "(1) 
Do you live in the . . . way of life? (2) Will you be a success 
in the . . . way of life?" Subjects are asked to evaluate their 
involvement and success in their traditional culture (e.g., Span- 
ish/Mexican American or American Indian) and the White 
American society. Integrating these two perspectives yields a 
model of acculturation that hypothesizes that successful adapta- 
tion to the Mexican and Anglo American cultures vary indepen- 
dently of each other. 



332 



Model of Independent 
Adaptation to Mexican and 
American Cultures 

According to the proposed model of independent adaptation to 
Mexican and American cultures, individual or group accultura- 
tion would be plotted in one of four quadrants as a function of 
quantitative assessment of degree of adherence to each culture. 
The four quadrants (see figure 14-1) created by the intersection 
of the two cultural axes are similar to the varieties of acculturation 
proposed by Berry (1990) but are relabeled with terms more 
commonly employed by Hispanic scholars to describe the accul- 
turative process (e.g., Keefe and Padilla, 1987; Mendoza and 
Martinez, 1981; Olmedo, 1980). For example, high adaptation 
to the Mexican culture accompanied by high adaptation to the 



Mexican Culture 



High 



Unacculturated 



White 

American 

Culture 



Low 



Marginal 



Bicultural 



High 



Assimilated 



Low 



Figure 14-h Model of Independent Adaptotion to 
Mexican and American Cultures 



333 






American society describes the variety of acculturation that Berry 
(1990) would call integration but Chicano scholars would term 
bicultural. Berry would have called low adaptation to the Ameri- 
can culture in combination with high adaptation to the Mexican 
culture separation, whereas the present model employs the more 
commonly used term unacculturated. 

This model of acculturation can provide a different perspec- 
tive on the relation of concepts such as anomie and acculturative 
stress to alcohol use. It has been suggested that anomie, or alien- 
ation from society, cannot account for Hispanic women's drink- 
ing patterns because their increased use of alcohol is associated 
with higher levels of education, income, working outside the 
home, and being U.S.-born (Caetano, 1990). Johnson and Matre 
(1978) failed to find that anomie predicted Mexican American 
gj drinking, and concluded that the concept was "an 'Anglo' con- 

^" cept that should not be applied to a person of another culture 

without adapting the concept to that culture" (p. 901). The new 
model allows for a different interpretation of these results. John- 
son and Matre (1978) suggested that an acculturated Mexican 
American woman's use of alcohol might not imply alienation 
from the Anglo American culture but the "degree to which she 
is alienated from her culture" (p. 901, emphasis added). Similarly, 
perhaps the educated Mexican American woman who works 
outside the household and drinks in a wide range of social set- 
tings may be experiencing stress related not so much to being out 
of harmony with non-Hispanic White norms but with Mexican 
cultural ideals about appropriate behavior for a woman. 

The lead article in a recent issue of Hispanic magazine 
(Anders, 1993) highlighted the conflicts that working Hispanic 
women experience when emerging from a culture that "encases 
the woman in the role of self-sacrificing mother and homemaker" 
(p. 14). One managerial-level working mother reported, "When 
I see a mom with a kid, it makes me feel bad because it's like 
I'm supposed to be doing that-because I've been raised that 
way" (p. 14). The article went on to report on the research of 
psychologist Lillian Comas-Diaz that found Hispanic women 
were experiencing pressure to be "superwomen" vis-a-vis both 
work and family requirements. She concluded, "because you 



334 



don't want to be fired from either job. That creates an added 
stress" (p. 18). 

While becoming better educated and working outside the 
household may show adaptation to the non-Hispanic White way 
of life, it may also imply alienation from the Mexican culture 
in terms of gender-appropriate roles. Gilbert (1985) noted that 
Mexican American women's drinking is limited to private set- 
tings with family and close friends. A woman who drinks in 
other settings may have decreased her adherence to the Mexican 
culture. Thus, an educated woman who works outside the house- 
hold and drinks in a variety of public settings might fall into 
the assimilated quadrant. In contrast, a Hispanic woman who 
expands her roles to include activities outside the household but 
retains cultural prohibitions about drinking would likely be in 
the bicultural quadrant. This perspective on the balance between 
Hispanic women's advancement in the American way of life and 
the degree of adherence to the Mexican culture has considerable 
implications for alcohol prevention and treatment. Education/ 
prevention programs could warn Hispanic women of the stresses 
associated with becoming successful in the non-Hispanic White 
way of life and /or the more liberal attitudes about women's use 
of alcohol in the dominant culture. Prevention and /or treatment 
could focus on retaining Hispanic cultural limitations on female 
drinking and /or suggest other options for coping with stress. 
Prevention messages aimed at the upwardly mobile Hispanic 
woman would, in effect, encourage movement from the unaccul- 
turated into the bicultural quadrant. 

Another example might help to bolster the proposition that 
adherence to traditional Hispanic cultural norms may be healthy 
for women, albeit perhaps not necessarily for men. Mexican 
immigrants have considerably less access to family and extended 
family (M = 5 relatives) than do their second and third genera- 
tion U.S.-born counterparts (M = 17 and 15 respectively) (Keefe, 
et al., 1978). This loss of familial support may influence Hispanic 
male and female drinking quite differently. Recently immigrated 
men are known to alter their drinking patterns from one of less 
frequent, high quantity drinking in Mexico to frequent, high 
quantity usage within five years of immigration (Caetano and 



335 



'■►,. 



Mora, 1988). In contrast, Mexican immigrant women are more 
likely to be total abstainers than their counterparts in Mexico, 
and those who do drink maintain the homeland's pattern of low 
frequency, low quantity drinking for females (Caetano and Mora, 
1988; Gilbert, 1989). Since Mexican women's drinking is confined 
to intimate settings with close friends and family (Gilbert, 1985), 
their small social network after immigration would offer fewer 
culturally sanctioned opportunities to drink. This could account 
for their tendency to consume even less than women in Mexico. 
For Mexican male immigrants, the loss of family-centered 
opportunities to drink may increase the frequency of their heavy 
drinking. Ethnographic research has suggested that saliency of 
drinking is limited at Mexican American family gatherings 
(Rodriquez- Andrew, et al., 1988). Only 3% of a California sample 
reported it was appropriate to get drunk in front of one's parents 
or children (Alcocer and Gilbert, 1979). Thus, for Mexican males, 
immigration leads to a decrease in opportunities for culturally 
moderated drinking in family settings. If these men are experi- 
encing stress related to difficulties in adjusting to the American 
way of life, they may seek the culturally sanctioned company 
of males at bars or other public settings where drinking becomes 
the focus of activity. A Mexican male immigrant who has not 
had much time to adapt to the non-Hispanic White way of life 
and experiences a decrease in the prophylactic features of his 
family-centered Mexican culture would likely fall into the mar- 
ginal quadrant. Prevention and treatment research could explore 
the effectiveness of enhancing family-centered social support 
systems as a means to moderate Mexican American male drink- 
ing. Such interventions would be capitalizing on one positive 
aspect of Mexican machismo, i.e., a man's desire to serve as a 
good model to his children. 

Assessment of Adaptation to 
Mexican and American Cultures 

The Mexican and American cultural model outlined above shows 
promise to address concerns in both the Hispanic mental health 
and Hispanic alcohol literatures. Unfortunately, development of 



336 



the theoretical underpinnings of the model has outdistanced 
evolution of accompanying measurement instruments. While 
many components of the requisite independent Mexican and 
American adaptation scales are clearly indicated by present con- 
sensus about variables influencing acculturation, the truly com- 
prehensive measurement of // Americanness ,, is very complex. 
Various different approaches have confirmed basic factors 
known to influence acculturation such as language familiarity, 
usage, and preference; generational status and ethnic identifica- 
tion; cultural exposure; and, social interactions (e.g., Cuellar, 
Harris, and Jasso, 1980). Items from existing linear bi-polar scales 
may be easily adapted to assess level of adaptation to the His- 
panic and American cultures independently. 

For example, linear models of acculturation are associated 
with items that ask if one speaks, reads, or writes better in English 
versus Spanish. Theory underlying the present model would 
dictate that inquiry be made about the two different cultures 
separately from each other. Thus, items should solicit degree of 
competence in the various components of each language — for 
example, "How well do you speak English?" and "How well 
do you write Spanish?" This allows for more comprehensive 
assessment of proficiency in both languages. A subject who indi- 
cates s/he reads or writes better in Spanish than in English 
may still be functionally illiterate in both. Where appropriate, 
knowledge of the limited reading and writing ability of a target 
population could save wasted efforts on producing prevention 
literature and dictate a focus on oral sources to disseminate 
prevention messages. This new approach to assessing accultura- 
tion adds a new dimension to the information available about 
subjects who would indicate they were equally adapted to the 
Mexican and American cultures. The quality of adaptation, i.e., 
equally adept and skilled or equally inept and unskilled, deter- 
mines placement in either the bicultural or marginal quadrant. 
A highly bicultural individual may well require different preven- 
tion and treatment intervention than a truly marginal person. 

Limitations of Measurement. There are aspects of success- 
ful adherence to the Mexican culture, such as the manner in 
which familism and religiosity are expressed (Cervantes and 



337 



Garcia, 1992), which do not have a clear and straightforward 
analogue in the non-Hispanic White way of life. Attempts to 
determine what values, behaviors, and beliefs connote successful 
adherence to the non-Hispanic White way of life have proven 
difficult. One is trying, in effect, to measure ' 'generic American- 
ness" in a society that is extraordinarily multi-ethnic in composi- 
tion. However, there is evidence that subjects can report on the 
degree to which they adhere to and anticipate being successful 
in the White American way of life (Oetting and Beauvais, 1990). 
Presently, research is under way to determine what constitutes 
living by and being successful in the Mexican American /His- 
panic and non-Hispanic White ways of life. This will, hopefully, 
advance and refine efforts to measure independent adaptation 
to the Mexican and American cultures. 

£ 

Conclusion 

While epidemiological information about Hispanic alcohol use 
has expanded tremendously in the past two decades (see Cae- 
tano, 1987, 1988a, 1988b; Gilbert 1988), this knowledge has not 
served to significantly advance efforts at primary or secondary 
prevention of Hispanic alcohol abuse. The present paper briefly 
explored some factors that are related to the lack of progress in 
alcohol prevention. The effects of past insensitivity to the impact 
of ethnic and racial diversity on alcohol-related problems and 
the failure of the culture of science to treat communities of color 
with respect have contributed to community leaders' resisting 
further research. The argument was made that reciprocal partner- 
ships between communities of color and investigators are neces- 
sary to overcome a long and negative history between the two. 
Various ways of engaging the Hispanic community into the 
process of facilitating prevention research were suggested. 

Investigators must become culturally competent to overcome 
a community's suspiciousness of research and hesitancy to 
engage in the research process. An investigator's basic orienta- 
tion to the integration of cultural variables into prevention 
research is differentially likely to alienate or engage the Hispanic 
community. While some comparison of Hispanic to non-His- 



338 



panic White patterns of alcohol use can be helpful to improve 
prevention efforts, shifting paradigms to examine Hispanic alco- 
hol use exclusively shows promise to increase our knowledge 
of vulnerability and resiliency factors. Also, viewing accultura- 
tion as a process of independent adaptation to Hispanic and 
American culture might help to better integrate and apply pres- 
ent results and further prevention of alcohol-related problems. 

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342 



15 



Alcohol Abuse Prevention 

Research in African 

American Communities 

John M. Wallace, Jr. and Lawrence S. Brown, Jr. 



Introduction 

Alcohol affects virtually every organ and tissue in the body 
deleteriously and is indirectly if not directly responsible for 
almost 100,000 deaths annually (United States Department of 
Health and Human Services [USDHHS], 1990, 1987). Besides 
the loss of many lives, it is estimated that alcohol abuse costs 
Americans more than $135 billion annually in lost employment, 
reduced productivity, and health care for alcohol-related condi- 
tions such as alcoholism, cirrhosis of the liver, and various forms 
of cancer (Hammond, 1991). Clearly, the toll that alcohol abuse 
exacts upon all Americans is tremendous, but, given high rates 
of poverty, chronic unemployment, and the lack of quality health 
care, the impact of alcohol upon African Americans is particu- 
larly pernicious. In fact, some have characterized alcohol abuse 
as the number one mental and social problem of Black Americans 
(Bourne, 1973; Harper, 1976; Watts and Wright, 1983). 



This paper was supported by a National Science Foundation Postdoctoral Fellow- 
ship to the first author. 



343 



h. 



After key demographic and social characteristics of the Afri- 
can American population are reviewed, this paper examines the 
prevalence and patterns of alcohol use among African Ameri- 
cans, the norms associated with their use of alcohol, the impact 
of alcohol abuse on their health and well-being, methodological 
issues and concerns in the study of their use and abuse of alcohol, 
the relationship between the alcohol industry and African Ameri- 
cans, and, finally, issues related to the prevention of alcohol 
abuse and alcohol-related problems among African Americans. 

The African American Population 

There are at least 31 million Americans of African descent in the 
United States, constituting more than 12 percent of the total 
population. Although most of them trace their roots to West 
Africa, African Americans are in reality a heterogeneous group, 
of Afro-Caribbean, Afro-Latin, Afro-Indian, Afro-European, and 
other descents. Accordingly, any effort to characterize the behav- 
ior of the "African American community" or "Black community" 
is difficult if not impossible. Nevertheless, without data that 
examines cultural and ethnic differences in the meanings, preva- 
lence, and patterns of alcohol use within the "Black" population, 
the present discussion focuses on the aggregate — all of those 
persons who define themselves, or who are socially defined, as 
"Black" or "African American." 

In addition to the racial and ethnic diversity within America's 
Black population, there is also considerable diversity in its socio- 
demographic characteristics. Some of these characteristics may 
place African Americans at greater than average risk for alcohol 
abuse, while others may act as protective factors against the 
abuse of alcohol. For example, although there is a broad age 
spectrum among African Americans, the population is relatively 
young, with more than 60% being under age 35 and a median 
age of 28 years (U.S. Census, 1992). This youthfulness, coupled 
with many Black people's ambivalence regarding the use of alco- 
hol, makes them prime targets for early prevention efforts. On 
the other hand, this youthfulness may make them especially 
vulnerable to experimentation with alcohol, family problems 



344 



related to the alcohol abuse, interpersonal violence, crime, and 
other difficulties associated with youthfulness and related to 
alcohol abuse. 

Beyond being relatively young, a sizable number of African 
American families (29 percent) are poor, with poverty being 
concentrated among children and single female parents (U.S. 
Census, 1992). Poverty, linked with the stress associated with 
being a single parent, may place many Black women and their 
children at increased risk for alcohol abuse and alcohol-related 
problems. A strong correlate, if not cause, of poverty and female- 
headed families is unemployment, particularly among males. 
The annual average labor force participation rate among Black 
men in 1991 was 70 percent (U.S. Census, 1992). High rates of 
unemployment, underemployment, and the subsequent inability 
to fulfill their role as economic providers may cause many Black 
men to experience increased psychological strain, thus placing 
them at high risk to abuse alcohol and other drugs. 

Linked to poverty, unemployment, and persistent institu- 
tional racism is the continued existence of residential segregation. 
As at least a partial consequence of residential segregation, more 
than half the Black population lives in the nation's central cities 
(U.S. Census, 1992). Because of their heavy concentration in inner 
cities, African Americans are exposed, disproportionately, to 
many liquor stores, bars, billboards, and other alcohol advertise- 
ments, all factors that place them at increased risk for alcohol 
abuse (Hacker, Collins, and Jacobson, 1987; Moskowitz, 1989). 

A major ' 'protective factor" against alcohol abuse to which 
many Black people are exposed is religion. Related to their south- 
ern heritage, many African Americans claim ties to Baptist and 
other fundamentalist religious denominations, many of which 
have strong abstinence beliefs and traditions (Herd, 1989). Absti- 
nence norms established at the denominational level and the 
congregational level, social involvement with other church mem- 
bers who abstain or drink very little, and individual beliefs that 
alcohol abuse is a violation of God's laws (i.e., sin), are clear ways 
in which church involvement can serve to reduce alcohol abuse. 

During the last 30 years there has been a growing segment 
of upwardly mobile African Americans who, through various 



345 



educational and other opportunities, have joined America's 
social and economic mainstream. On the other hand, there per- 
sists to be many disadvantaged Black people who experience 
poverty, unemployment, single parent families, residential segre- 
gation, continuous exposure to pro alcohol messages, and no 
religious affiliation. This "high risk" group is often the focus of 
media reports and scientific research, while the lifestyles and 
patterns of behavior found in the general African American pop- 
ulation are often unexplored. In the next section a broader per- 
spective is taken to examine the norms, patterns, and prevalence 
of alcohol use and abuse among African Americans. 

Alcohol and African Americans 



The most recent Secretary of Health and Human Services Report 
on Alcohol (USDHHS, 1990a) correctly notes that "alcohol 
research has only recently begun to focus on racial and ethnic 
minorities" (p. 32). Alcohol abuse has long been assumed to be 
a problem among African Americans, but until recently very 
little research examined this assumption empirically. An early 
literature search of over 16,000 alcohol-related studies reported 
in scientific journals between 1939 and 1974 yielded only 77 
articles that discussed findings related to Black people (Harper 
and Dawkins, 1976). Since the mid-1970s there has been an 
increase in the research on African Americans' alcohol use and 
a concomitant growth in knowledge about this important topic. 
Despite the increase in research on the use of alcohol among 
African Americans, however, empirical evidence drawn from 
different sources yields information that both confirms and con- 
tradicts the assumption that there is a great amount of alcohol 
abuse among Black people in America. For example, survey 
research indicates that Black Americans drink less, on average, 
than do other groups and that they are more likely than others 
to abstain from any use of alcoholic beverages (Herd, 1989). On 
the other hand, survey data also suggest that Black people who 
do drink are more likely than average to experience alcohol- 
related problems (Herd, 1991). These issues are examined more 
closely below. 



346 



Prevalence and Patterns 

The extant research shows that there are significant within and 
between race differences in the prevalence of alcohol use and 
in the relationship between alcohol use and several important 
demographic characteristics including gender, age, income, and 
location of residence (Herd, 1991). 

Gender. Alcohol use among Black males exceeds that of 
Black females, among both young people and older adults (Bach- 
man, et al., 1991; Herd, 1989). For example, Bachman, et al. (1991) 
report that 49% of Black male high school seniors used alcohol 
in the last 30 days compared to only 33% of Black females. 
Similarly, male seniors (24 percent) were almost three times as 
likely as female seniors (9 percent) to be binge drinkers (i.e., five 
or more drinks, in a row, within the last two weeks). Findings 
from the 1984 National Alcohol Survey (Herd, 1991) are consis- 
tent with those from seniors. Nearly half the Black women (46 
percent) reported that they abstained from alcohol use compared 
to only 29 percent of Black males, and only 4 percent of the 
women were frequent heavy drinkers compared to 15 percent 
of the men. 

Turning to race differences, in the National Alcohol Survey 
the drinking patterns of Black and White men were similar, but 
Black men were slightly more likely to abstain (29 percent versus 
24 percent) and slightly less likely to be heavy drinkers (15 
percent versus 19 percent). Among females, roughly equal pro- 
portions were heavy drinkers (i.e., 4 percent of Black women 
and 5 percent of White women), but Black women were much 
more likely than White women to abstain (46 percent versus 34 
percent) (Herd, 1991). 

Age. Existing evidence suggests that there are important 
age-related differences in the patterns of alcohol use among Black 
people and between Black people and White people. Table 15- 
1 presents recent findings from national samples of Black and 
White 8th, 10th, and 12th graders. The data indicate that, on 
average, alcohol use increases with age among Black students. 
An interesting exception to this general rule is the slightly lower 
prevalence of heavy drinking (i.e., 5 or more drinks in a single 



347 



K, 



• 



Table 15-1: Lifetime, Annual Thirty-Day, and Heavy Recent 
(5 or more drinks in a single sitting in the last two weeks) 
Alcohol Use, by Race and Grade Level 



Lifetime 



Annual 



Thirty-Day 



5 + Drinks 



Grade White Black White Black White Black White Black 
8th 71.8 64.5 56.0 43.6 26.0 17.8 12.6 9.9 



10th 
12th 



85.6 
89.8 



78.5 
80.3 



75.4 
80.5 



60.8 
64.3 



45.7 
57.7 



30.2 
34.4 



24.4 
32.9 



14.4 
11.8 



Source: Johnston, L.D., O'Malley, P.M. and Bachman, J.G. Smoking, Drinking, 
and Illicit Drug Use Among American Secondary School Students, College 
Students, and Young Adults. Vol. I. Table 10, Rockville: USDHHS, 1992. 

sitting) among 12th graders relative to 10th graders. While it is 
possible that this finding occurred by chance, it is also possible 
that Black youth who drink heavily do not stay in school until 
their senior year, and thus they are not in the sample of seniors. 
Concerning race differences, the table shows that Black stu- 
dents are less likely than White students to have ever used alco- 
hol, to have used alcohol in the past year, to be current drinkers, 
or to drink heavily. It should be noted that the magnitude of 
the race differences in use is largest among seniors; however, 
some of this difference may be the result of the slightly higher 
national dropout levels among Black students compared with 
White students. Data from the 1991 National Household Survey 
(National Institute on Drug Abuse, 1992) is consistent with the 
student findings: Black people in each age category are less likely 
than their White counterparts to drink (see Table 15-2). It should 
be noted, however, that the age-related prevalence differs by 

Table 15-2. Lifetime, Annual, Thirty-Day Alcohol Use, by Race and Age 





Lifetime 


Annual 


Thirty-Day 


Age 


White 


Black 


White 


Black 


White Black 


18-25 


93.2 


82.5 


86.8 


72.8 


67.2 56.0 


26-34 


94.4 


88.6 


83.7 


72.7 


63.8 57.1 


35 + 


88.7 


84.3 


66.2 


56.6 


50.9 40.3 



Source: National Institute on Drug Abuse (NIDA), National Household Survey on 
Drug Abuse: Population Estimates 1991 (Revised November 20, 1991, Tables 13-B 
and 13-D. Rockville: USDHHS, 1992. 



348 



race. Among the White respondents, use is highest among the 
youngest age group (18-25) but declines thereafter. Among Black 
respondents, however, there is no difference in the level of use 
among the youngest respondents and those in the middle group. 
The decline in use among Black respondents does not begin until 
after age 35. 

Income. Past research, conducted on predominantly White 
samples, indicates that alcohol use is typically highest among 
those with high incomes (Herd, 1991). In contrast, among Black 
people, the prevalence of heavy alcohol use is highest among 
moderate income males and females and lowest among those in 
the highest income category (i.e., $30,000 and over) (Herd, 1991). 
Among White respondents, heavy use was highest among males 
in the highest income category and among females in the moder- 
ate income categories. 

Not surprisingly, research that has explored alcohol use in 
low income areas (e.g., housing projects) has found higher rates 
of heavy drinking among Black respondents than those reported 
in national samples (Herd, 1989). This finding suggests that alco- 
hol abuse and alcohol-related problems, like most social prob- 
lems, are disproportionately located among those who are poor. 

Region and Urbanicity. The region of the country and the 
size of the city in which one lives is related to the prevalence 
and level of alcohol use (USDHHS, 1990). Nationally, for Black 
men, abstinence is highest in the Northeast (34 percent) and the 
South (34 percent) and lowest in the North Central (17 percent) 
and Western regions (20 percent) (Herd, 1991). Frequent heavy 
use among men is lowest in the North Central region (12 percent) 
and only slightly higher in the Northeast, South, and West (16 
percent, 15 percent, and 15 percent, respectively). The size of the 
community has relatively little impact on the level of abstinence 
among Black men. On the other hand, heavy drinking is twice 
as prevalent in large metropolitan areas (20 percent) as in smaller 
metropolitan (10 percent) areas and non-metropolitan areas (10 
percent). Among Black women, abstinence is highest in the South 
(56 percent), lowest in the North Central region (31 percent), 
and intermediate in the Northeast (34 percent) and the West (34 
percent) (Herd, 1991). The prevalence of frequent heavy drinking 



349 



among Black women is low across regions, with it being the 
highest in the West (7 percent), followed by the North Central 
(6 percent), the South (4 percent) and the Northeast (3 percent). 
Community size also significantly relates to abstinence among 
Black women. Abstinence is highest in non-metropolitan areas 
(59 percent) and roughly the same in large and medium-sized 
metropolitan areas (42 percent and 41 percent, respectively). The 
prevalence of heavy drinking is not significantly different in 
large metropolitan areas (5 percent), medium metropolitan areas 
(4 percent) and non-metropolitan areas (4 percent). 

Despite evidence from national surveys that Black Americans 
are more likely to abstain from alcohol use and drink less than 
Whites, local surveys and ethnographic data suggest that alcohol 
use and abuse are widely spread problems among African 

N Americans, particularly in urban, high density, low socio-eco- 

«!! nomic areas. Samples drawn from New York state, Boston, New 

S ^ ,:;, York City, New Haven and St. Louis all found similar levels of 

heavy drinking among Black men and high levels of abstinence 

and high levels of heavy drinking among Black women who 

> drink (Herd, 1989). 

Norms. Recent survey research and ethnographic studies 
have given insight into the norms and values associated with 
alcohol use among African Americans (Herd, 1989). Many Afri- 

H can Americans hold ambivalent attitudes toward alcohol. This 



ambivalence, and the extremes of abstinence and heavy use that 
characterizes the alcohol consumption patterns of many African 
Americans, has been called the "two worlds" of Black drinking 
(Herd, 1989). According to Herd (1989), the first "world," the 
abstinence norm, is much the result of Blacks' southern, rural, 
and fundamentalist religious heritage. The second world, heavy 
use, is associated with the night club culture that developed 
before and during Prohibition. The night club culture typically 
centers on bars, taverns, and clubs where alcohol is served regu- 
larly and, along with music and dancing, is part of the social 
atmosphere that characterizes these establishments (Herd, 1989). 
Beyond use in clubs, bars, and other businesses where alcohol is 
consumed, most alcohol use among the general Black population 
occurs on weekends and during holidays, weddings, and other 
special occasions. 



350 



Alcohol Problems and African 
Americans 

For the purposes of the present discussion there are two broad 
categories of alcohol-related problems: psychosocial problems 
(e.g., injuries, crashes, crime, interpersonal problems, etc.) and 
physiological problems (e.g., cirrhosis, throat cancer, and other 
alcohol-related diseases). The extent to which these various prob- 
lems impact the African Americans are discussed below. 

Psychosocial Problems 

Approximately 18 million adults currently experience problems 
because of alcohol use (USDHHS, 1990). These problems include 
crime, automobile accidents, impaired job performance, suicide, 
homicide, and difficulty in personal relationships. Ravenholt 
(1987) estimates that 30% of the suicides and 50% of the motor 
vehicle accidents and homicides are related to alcohol use. 
According to United States Department of Justice (1985) statistics, 
54% of the persons convicted for violent crimes used alcohol 
before they committed their offense. These violent crimes include 
murder /attempted murder, manslaughter, rape /sexual assault, 
robbery, and assault. Forty percent of the persons convicted for 
property crimes (e.g., burglary, auto theft, arson, destruction of 
property, and larceny) and 64% of the persons committing public 
order crimes (e.g., weapons possession, obstruction of justice, 
and driving while intoxicated) had recently used alcohol before 
their arrest (USDHHS, 1987). 

Despite the fact that relatively higher proportions of Black 
people are incarcerated for various crimes, data from arrest 
records, prison records and interviews do not support the notion 
that Blacks who are arrested are more likely to drink heavily 
than Whites. According to Herd (1989), prison studies show that 
a smaller proportion of Black than White male offenders were 
drinking or intoxicated at the time that they committed their 
crimes. 

Although Black Americans do not appear to suffer some of 
the negative effects of alcohol to as great an extent as Whites for 



351 



N 



1 • 



things such as auto accidents or suicide, data from the National 
Alcohol Survey suggest that Black men experience a higher level 
of alcohol-related problems than do White men for every prob- 
lem except drunk driving (Herd, 1991). The problems that the 
study examined included financial problems, accidents, binge 
drinking, loss of control, alcohol withdrawal symptoms, belliger- 
ence, job problems, police problems, spouse problems, people 
problems, and health problems. 

Race differences in alcohol-related problems varied by age 
and income. For White drinkers, problems peaked during late 
adolescence and early adulthood. Among Black drinkers, how- 
ever, alcohol-related problems continued to increase until they 
reached their middle 30s (Herd, 1991). As income increased 
among Black males the number of alcohol-related problems 
decreased. For White males, however, alcohol-related problems 
were highest for those in the highest income category. 

Physiological Problems 

Numerous physical ills have been associated with alcohol abuse. 
Alcohol affects the central nervous system, the endocrine system, 
the reproductive system, and the digestive tract. Alcohol has 
also been associated with hypertension, pneumonia, influenza, 
and various cancers including cancer of the lip, mouth, pharynx, 
larynx, and stomach (USDHHS, 1990). 

Epidemiological data show that cirrhosis of the liver is a 
primary physical consequences of alcohol abuse. Between 1960 
and 1970 the cirrhosis mortality rate of the non- White population 
doubled from about 12 to almost 24 deaths per 100,000 (Herd, 
1989). During this ten-year period the cirrhosis deaths for non- 
White men increased by 276%; for White males the rate increased 
by 66 percent. The cirrhosis death rate for non-White women 
increased by 205% while the rate for White women increased 
by 54% (Herd, in 1989). Since 1973 the cirrhosis rate has declined 
for all racial groups. Despite this general decline, the cirrhosis 
mortality rate for Black Americans continues to be disproportion- 
ately high. Although the number of cirrhosis deaths has 
decreased significantly, the ratio of deaths between Whites and 
non-Whites has remained largely unchanged. Non-Whites still 



352 



die at almost twice the rate of Whites (20.0 and 11.1 deaths per 
100,000, respectively) (USDHHS, 1987). Hacker, et al. (1987) cite 
a government study of seven major U.S. cities that found that 
the cirrhosis mortality rate for non- Whites ages 25-34 was more 
than ten times the rate for Whites. 

Like cirrhosis of the liver, esophageal cancer is also linked 
to heavy alcohol consumption. Between 1979 and 1981 the rate 
of esophageal cancer for Black males 35-44 years old was ten 
times the rate for Whites. The rate for Black women was three 
to seven times that of White women (Report of the Secretary's 
Task Force, 1985). Besides higher rates of cirrhosis and esopha- 
geal cancer, Blacks also disproportionately suffer other physical 
consequences of alcohol abuse. These problems include hyper- 
tension, obstructive pulmonary diseases, severe malnutrition, 
and birth defects (USDHHS, 1990). 

Methodological Issues and 
Concerns 

Many methodological issues are of concern as they pertain to 
research on the use and abuse of alcohol among African Ameri- 
cans. These issues include the samples upon which a given piece 
of research is based, the method of data collection, and potential 
race and class biases in the reporting of "objective" data. 

Important distinctions between local samples and national 
samples, men and women, youth and adults, regional differ- 
ences, poor versus middle income, metropolitan versus non- 
metropolitan, and other distinctions noted above are seldom 
made in discussions of alcohol use and abuse among African 
Americans. One reason for the failure to make these distinctions 
is the over-emphasis most research places on cross-race compari- 
sons (e.g., Black- White differences) than on within-race similarit- 
ies and differences. Because of this over-emphasis on race com- 
parisons, there is a certain amount of inconsistency and confusion 
about the actual prevalence and patterns of alcohol use among 
African Americans and the location (e.g., social class, family 
structure, urbanicity) of alcohol-related problems. 



353 



The race difference emphasis is, perhaps, most problematic 
when the findings from typically small, non-representative, sam- 
ples of African Americans (e.g., from treatment centers or hous- 
ing projects) are extrapolated to represent all African Americans 
and /or are contrasted with findings from representative samples 
of White people. A clear distinction needs to be made between 
research that explores race differences in alcohol use and research 
that examine alcohol use within the African American popula- 
tion. Put another way, the purpose of the research and the 
research questions being posed must be clearly articulated, and 
the limitations and generalizability of the findings acknowl- 
edged. 

Several methods of data collection are used to gather informa- 
tion on alcohol use and abuse. These methods include the use 
of surveys and questionnaires, ethnographic studies, and the use 
|C of "official" statistics such as death certificates and data from 

W alcohol treatment centers. The sensitive nature of questions about 

alcohol abuse might increase the likelihood of systematic non- 
response from African American respondents. Systematic non- 
response, small, non-random samples, and the fact that school 









samples and household samples miss those groups most likely 
to abuse alcohol (e.g., dropouts, the homeless, and incarcerated 
persons) are all important limitations. Recognizing the limita- 
tions of survey research, it should be noted that qualitative meth- 
ods are no panacea, given their typically small samples, difficulty 
in replication, and limited generalizability. Aggregate statistics, 
epidemiological studies, and other "objective" government data 
are also limited. Aggregate-level data mask individual differ- 
ences and often only indicate the overall prevalence of various 
alcohol-related diseases and problems without controlling for 
such factors as income, education, or regional difference. When 
these distinctions are not made it is almost impossible to deter- 
mine, beyond race and gender, what segments of the population 
are most adversely affected by alcohol. 

Even apparently objective data such as that garnered from 
death certificates is potentially problematic. Because of the diffi- 
culty in ascertaining any one problem as the cause of death 
and the stigma associated with alcohol abuse, doctors may be 



354 



reluctant to identify alcoholism as the primary cause on death 
certificates. This reluctance may be particularly true when the 
decedent is White and middle class (USDHHS, 1987). Accord- 
ingly, statistics on race differences for alcohol-related causes of 
death may be distorted; the true number of deaths from alcohol- 
related causes may be either overestimated for Blacks or underes- 
timated for Whites. 

Data from treatment centers may also present an inaccurate 
picture of race differences in the concentration of alcohol-related 
problems. According to extant data, African Americans are over- 
represented in community-based treatment centers. In reality, 
however, the heavier concentration of African Americans in com- 
munity-based treatment centers may result from the fact that 
they lack health insurance and other economic resources that 
would allow them to seek private treatment. 

The existing research has only begun to shed some light on 
the complex issue of alcohol and the African American commu- 
nity. Multiple data sources as well as multiple data collection and 
analysis methods are needed to fully understand the patterns, 
prevalence, norms, and problems associated with alcohol use 
among African Americans of different ages, genders, socio-eco- 
nomic strata, religious orientations, cultural backgrounds, and 
geographic locations. 

The Alcohol Industry and African 
Americans 

The alcohol industry has a central place in the American econ- 
omy. In 1990, consumers purchased 86.6 billion dollars in beer, 
wine, and distilled spirits (Hammond, 1992:5). The industry 
employs more than 800,000 people and has a payroll of more 
than $15 billion (Hammond, 1991:123). Not only is the alcohol 
industry an important source of jobs, it is also a large source of 
tax revenues. In 1989, taxes from the sale of wine, beer, and 
distilled spirits totaled $13.5 billion (Hammond, 1991:122). It 
should be kept in mind that the amount of taxes is less than 10 
percent of the annual cost of alcohol-related problems of $136.3 
billion (Hammond, 1991:120). Put another way, every dollar of 



355 



K 






alcohol tax collected costs Americans $10.09 in alcohol-related 
medical costs, lost productivity, crime, and other problems 
(Hammond, 1991:121). 

Targeting African Americans 

Although the specific demographic characteristics (e.g., sex, age, 

education, income) of the African Americans who purchase and 

consume alcoholic beverages are not well known, we do know 

that the alcohol industry spends over a billion dollars annually 

to market its product and that African Americans are targeted 

disproportionately as consumers (Hacker, et al., 1987; Scott, et al., 

1992). The alcohol industry uses the mass media (i.e., television, 

radio, and print media), outdoor advertising (billboards, posters, 

etc.), fund-raising events, community service campaigns, and 

Black advertising firms to promote their products among African 

K Americans. Through advertising, sponsoring activities, and other 

fj? N J? ventures, alcohol companies provide thousands of jobs and mil- 

] J lions of dollars in contracts to minority businesses (Hacker, et 

al., 1987). 

The alcohol industry not only provides jobs and contracts 
for minority businesses, but also it gets involved in various com- 
munity activities and efforts to create and sustain a positive 
image within the community. The list of Black individuals, orga- 
nizations, and institutions that receive philanthropic funds from 
the alcohol industry includes Black social, political, and even 
spiritual leadership (see Hacker, et al., 1987). 

The industry hires Black advertising agencies to conduct 
research and to develop sophisticated Black-oriented advertising 
programs that use African American language, culture, and role 
models to sell alcoholic beverages. Alcohol producers also spend 
a significant amount of money to advertise on Black radio sta- 
tions, not only to advertise alcoholic beverages but also to inform 
Black listeners of the various concerts and programs that the 
industry sponsors. Billboard advertising is yet another medium 
used to target African Americans. Evidence from various major 
cities shows that Blacks are disproportionately targeted by bill- 
board ads. A report on the top twenty-five population markets 
indicates that over 70% of the ad money spent for the eight- 



356 



sheet billboards are directed at Blacks, and alcohol ads account 
for about 37% of that amount, second only to cigarettes (Hacker, 
et aL, 1987). 

Coupled with the higher concentration of billboards in the 
Black community is the equally high concentration of alcohol 
outlets (Dawkins, et al., 1979). Liquor stores are highly visible 
parts of residential areas heavily populated by Black people. 
Conversely, in White communities the liquor stores and bars are 
typically located in commercially zoned business areas (Hacker, 
et al., 1987). 

It is not possible to draw a direct causal link from the alcohol 
industry's race-specific advertisement targeting to the negative 
health outcomes that alcohol use and abuse have on many Black 
people each year. Nevertheless, it seems very plausible that the 
money the alcohol industry pumps into Black employment, 
advertising, community service, and other organizations helps 
to silence efforts by Black celebrities, leadership, and even 
churches to make African Americans aware that the legal drug, 
alcohol, devastates more families and takes more lives than all 
the illicit drugs combined. The economic dependence that many 
Black corporations and individuals have on the alcohol industry 
may limit their ability (or desire) to ''bite the hand that feeds 
them," or to make Black people aware that they are dispropor- 
tionately targeted to purchase and consume alcoholic beverages. 

Prevention 

Prevention can be defined simply as an effort to keep something 
from happening. As it relates to alcohol, prevention goals may 
be to keep those who drink from experiencing the negative conse- 
quences associated with abuse (secondary prevention) or to keep 
those who do not drink from initiating (primary prevention). 
Most often, primary and secondary prevention are directed at 
youth and young adults, those populations most likely to experi- 
ment with alcohol and to use alcohol heavily. Accordingly, much 
of the discussion below focuses on young people. 

Existing research has highlighted numerous intrapersonal, 
interpersonal, and environmental "risk factors" that increase 



357 



K 



the likelihood that an individual will abuse alcohol, as well as 
"protective factors" which buffer, or reduce, the likelihood of 
alcohol abuse (for more extensive discussions see Goplerud, 1992; 
Hawkins, et aL, 1992; Clayton, 1992). Several of these risk and 
protective factors are discussed below, focusing particular atten- 
tion on their relationship to alcohol use and abuse among African 
Americans. 



Risk and Protective Factors for Alcohol 
Abuse 

Like most alcohol research, the vast majority of the research on 
risk and protective factors has been done using predominantly 
or exclusively White samples. Accordingly, the extent to which 



hj! many intrapersonal, interpersonal, and environmental risk and 

s' protective factors discussed below influence alcohol abuse 

among African Americans is not yet known (see Farrell, et al., 
1992; Newcomb and Bentler, 1986; Harford, 1986). 

Intrapersonal. Past research has identified a number of 
intrapersonal and other individual level risk factors and protec- 
tive factors related to the abuse of alcohol and other drugs. The 
intrapersonal risk factors include sensation seeking, poor grades, 
truancy, low self-esteem, depression, lack of bonding to societal 
institutions (family, school, community, work, church), rebel- 
liousness, delinquency, positive attitudes toward alcohol, and 
expectation to drink in the future. Intrapersonal protective factors 
include the inverse of the risk factors (e.g., high self-esteem, 
strong attachment to society) and other variables like internal 
locus of control, self-discipline, religiosity, and positive expecta- 
tions about the future. Low bonding to school (e.g., poor grades 
and truancy) has been found to significantly relate to alcohol 
use among African American youth (Farrell, et al., 1992; Wallace, 
1993), but the salience of many other intrapersonal variables as 
alcohol risk and protective factors has not been well established. 
Interpersonal. Interpersonal risk and protective factors are 
those that result from interaction with others. The interpersonal 
risk and protective factors most often cited are those related to 
family and peers (Catalano, et al., 1992; Barnes and Welte, 1986; 



358 



Hawkins, et al., 1992). The family and peer risk factors include 
modeling of alcohol abuse by parents and siblings, high levels 
of family conflict, parental absence, high levels of family stress, 
peer pressure to drink, peer rejection, high levels of peer involve- 
ment, and perceived and actual alcohol use by peers (Hawkins, 
Catalano, and Miller, 1992). Interpersonal protective factors 
include warm personal relationships with parents, family stabil- 
ity, and limited alcohol use by parents and peers (Hawkins, et 
al, 1992; Moskowitz, 1989). In general, the peer risk factors have 
been found to be significantly related to alcohol use among Afri- 
can American youth (Farrell, et al, 1992; Wallace, 1993), but 
again, the extent to which the other risk and protective factors 
impact their alcohol use has not been well researched. 

Environmental Factors. Several environmental factors 
have been theorized or empirically demonstrated to affect the 
likelihood that a given individual will use or abuse alcohol. 
Environmental risk factors include those that relate to the broader 
social environment (e.g., racism) as well as those that relate 
specifically to alcohol. The research indicates that alcohol con- 
sumption and alcohol-related social and physical problems are 
highest where there are high levels of poverty, unemployment, 
and crime, where there are high concentrations of alcohol outlets 
and low alcohol prices, where Sunday sales and advertising are 
not restricted, and where the minimum drinking age is low 
(Moskowitz, 1989; O'Malley and Wagenaar, 1991). Environmen- 
tal protective factors include laws unfavorable toward consump- 
tion, high taxation, low concentration of alcohol outlets, and 
restrictions about when and to whom alcohol may be sold 
(Moskowitz, 1989; Hawkins, et al., 1992). 

Because a third of African Americans live below the poverty 
level, many African Americans are at elevated risk for alcohol 
abuse. Specifically, crime, overcrowding, and other poverty- 
related factors clearly affect many African Americans. Low 
income African Americans are disproportionately exposed to 
many alcohol-specific risk factors, including low prices, abun- 
dant advertising, and high levels of availability. The "40 ounce" 
malt liquor, ubiquitous in African American communities, is a 
particularly poignant example of availability. The "40" is over- 



359 



sized, relatively inexpensive, extremely high in alcohol content 
(e.g., some brands have a higher alcohol content than a six-pack 
of regular beer), and heavily sold and marketed within Black 
communities (Scott, et al., 1992). 

Prevention Measures 

Because the risk factors for alcohol abuse exist at multiple levels 
(i.e., intrapersonal, interpersonal, and environmental), preven- 
tion efforts should target multiple levels of risk (see Pentz, et 
al, 1989). Several recent publications have highlighted single 
and multiple level prevention efforts among African Americans 
(USDHHS, 1990; Goplerud, 1992; Oyemade and Brandon- 
Monye, 1990; USDHHUD, 1992). 

Efforts that target intrapersonal risk factors for alcohol abuse 
ri include a variety of programs, including individual counseling, 

remedial education, life skills training, stress management, social 
influence, resistance training, values clarification, decision mak- 
ing, goal setting, vocational counseling, and involvement in alter- 
native activities (see Goplerud, 1992; Hansen, 1992; Hawkins, et 
al., 1992). Programs intended to affect interpersonal risk factors 
for alcohol abuse focus on family support, parenting skills, early 
childhood education, the reduction of interpersonal aggression, 
peer and family counseling, increasing the strength of family 
relationships, and developing positive peer groups (Goplerud, 
1992; Hawkins, et al., 1992; Tobler, 1986). Environmental preven- 
tion efforts include increased taxes on alcoholic beverages, laws 
restricting the days and hours of alcohol sales, minimum drink- 
ing age laws, restrictions on the location of alcohol outlets, and 
the creation of community level norms opposed to alcohol abuse 
(Moskowitz, 1989). 

The Effectiveness of Prevention 

Although the number of prevention programs has increased 
greatly in recent years, published evaluations of programs that 
target African Americans are virtually non-existent (see 
Goplerud, 1992). Accordingly, the extent to which various pro- 
grammatic and policy efforts have been able to reduce alcohol 



360 



initiation or alcohol abuse among African Americans is not yet 
known. A major issue expected to impact the effectiveness of 
prevention efforts directed toward Africans Americans is the 
extent to which these efforts are culturally specific. Based on the 
financial harvest that the alcohol industry and alcohol outlets 
reap in poor African American communities, it appears that 
culturally specific, targeted marketing is quite effective. How- 
ever, given the heterogeneity within the African American popu- 
lation, the "culture" to which a particular program should be 
// specific ,, is not always clear (e.g., a "culturally specific" preven- 
tion message effective with a young Black male in Harlem may 
be meaningless to a Black girl in rural Mississippi). The imple- 
mentation of intrapersonal and interpersonal prevention efforts 
may be particularly difficult for non- African Americans or indi- 
viduals of any ethnicity /race who lack contact with and /or who 
are insensitive to and ignorant about the culture of the targeted 
population (MEE Report, 1992). 

Several prevention programs and policies have been evalu- 
ated concerning their effectiveness in the general population. 
The extent to which these efforts have been effective varies con- 
siderably. For example, recent research suggests that taxation 
and laws regulating the sale and use of alcohol are relatively 
effective in reducing alcohol abuse and related problems 
(Moskowitz, 1989). On the other hand, individual level preven- 
tion programs appear to have relatively little impact on alcohol 
abuse (Hawkins, et al., 1992; Moskowitz, 1989). 

Beyond "Programs": Recommendations 
for Prevention 

Intuitively, it is expected that programs adapted for and specifi- 
cally created for African Americans will be more effective than 
generic programs; but, as noted before, prepackaged "programs" 
which focus exclusively on individuals hold little promise to 
prevent alcohol use and abuse, particularly if by programs one 
means one-shot or limited duration activities in which young 
people attend a class or two, participate in a few role plays, 
receive a special t-shirt, and are taught to repeat a catchy phrase. 



361 



Many "programs" are similar to get-rich-quick schemes and fad 
diets that promise maximum results with minimum effort. In 
the real world, those who can successfully amass and retain 
wealth or who can lose and maintain weight loss are those who 
are disciplined, who can obtain the requisite knowledge, and 
who invest the time and hard work necessary to achieve their 
goals. 

Just as there are no easy roads to wealth, health, or any other 
desirable goal, there is no easy way to prevent alcohol abuse 
among young people, particularly when alcohol is so widely 
used, so universally accepted, and so aggressively marketed. 
There are existing program curricula and other materials that 
have been shown to be effective in increasing young people's 
knowledge about alcohol and the problems associated with its 
£j abuse (Hansen, 1992). There are also curricula and materials that 

£? teach young people how to make decisions and how to resist peer 

pressure to drink. In short, there is an abundance of knowledge- 
based skills and abilities which existing "programs" can develop 
in young people. Nevertheless, it is Polly annic to believe involve- 
ment in "programs," taken alone, will keep young people from 
using alcohol or prevent the myriad problems associated with 
alcohol abuse. In order for alcohol abuse and other social prob- 
lems to be prevented, young people must be embedded in func- 
tioning, interconnecting social support networks (Price, et al., 
1993) committed to the goal of prevention. These networks 
include, but are not limited to, family, peers, community resi- 
dents, schools (i.e., students, teachers, administrators), churches, 
youth-serving organizations, businesses, and the communities 
in which these young people reside. 

Effective programs will certainly attempt to incorporate the 
best of what is available in terms of prevention curricula, but 
this step is only the beginning. The most effective "programs" 
will begin with parents and significant others who model absti- 
nence or restricted patterns of use, who explicitly state their 
values and expectations regarding alcohol use, who monitor 
their children's activities and peers, and who create, participate 
in, and support activities in which their youth are involved. 
The most effective programs will involve long-term relationships 



362 



with caring family members, friends, teachers, church leaders 
and members, and others from whom young people receive love, 
guidance, respect, and discipline. Prevention "programs" can 
never substitute for these relationships. 

Summary 

Although there is a massive literature on alcohol use and abuse 
in this country, relatively little of the research focuses on African 
Americans. Accordingly, much theoretical, epidemiological, and 
etiological research is needed to clarify the patterns, norms, prev- 
alence, correlates, causes and consequences of alcohol use and 
abuse among the nation's Americans of African descent. Further 
research is also necessary to identify the risk and protective 
factors that are most salient for African Americans. 

National prevalence data suggest that African Americans are 
no more likely to use alcohol than the general population. On the 
other hand, research on alcohol-related mortality and morbidity 
suggests that African Americans are more likely than average 
to experience alcohol-related problems. The extent to which these 
problems are the result of macro-level social factors, such as 
poverty, unemployment, and institutionalized racism, rather 
than race, per se, is not clear. Nevertheless, the disproportion- 
ately high prevalence of alcohol-related illness, death, and other 
social problems among African Americans shows that the need 
to prevent alcohol abuse, particularly among young people, is 
imperative. 

Ultimately, individuals decide the extent to which they will 
become involved with alcohol. Nevertheless, this decision does 
not occur in a vacuum; rather, it is influenced greatly by individu- 
als' primary relationships and the social contexts in which they 
are embedded. Accordingly, prevention efforts must not be 
directed toward individuals only, but also toward the experi- 
ences, relationships, activities, institutions, and communities cen- 
tral to their everyday lives. 

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' 



i 



366 



16 



Alcohol Prevention Research 

in Black American 
Communities 



Patricia A. Seabrooks 



Introduction 

A review of the alcohol abuse prevention literature on Black 
American communities reveals a paucity of attention to the chal- 
lenges facing researchers and community members who are try- 
ing to develop collaborative relationships to prevent alcohol- 
related problems in the community. This paper identifies some 
of these challenges, drawing from the perspective of community 
members and organizations. 

The community of Miami-Dade County, Florida, is used to 
illustrate some of the barriers, successes, and not yet completed 
projects that address the commitment to collaborative relation- 
ships between researchers and community members. The com- 
munity of Miami-Dade County represents a multicultural, multi- 
racial, economically diverse environment that is often confronted 
by multiple complex and conflicting health care and social issues. 
Alcoholism and alcohol abuse prevention and treatment repre- 
sent the more challenging issues with which the community 
is faced. 

After a description of the Miami-Dade County community 
and a brief review of alcohol-related problems of the community, 
the remaining sections of the paper address some challenges 



367 



facing researchers and community members in Black American 
communities as they attempt to build collaborative relationships. 

Miami-Dade County, Florida 

Description of the Community 

There are three primary ethnic groups who reside within the 
boundaries of the Family Health Center (FHC) in Miami-Dade 
County, Florida. These include American and Caribbean Blacks 
who live in the Liberty City and Brownsville communities, His- 
panics primarily from Cuba but also from other Spanish-speak- 
ing countries such as Nicaragua and Colombia who reside pri- 
^ marily in Hialeah and Allapattah, and Haitian immigrants (both 

P documented and undocumented) who live predominantly in the 

Edison /Larchmont areas commonly referred to as "Little Haiti." 
Although the community health center serves several ethnic 
groups, Black Americans from Liberty City, an area in which 
over 80% of the residents are at or below the poverty level, 
constitute the single largest group. This is in contrast to the rest 
of the county where 50% of residents are at or below the poverty 
level. The area known as "Little Haiti" consists primarily of 
Haitian immigrants (legal and illegal), while Hialeah consists 
mainly of blue-collar Cuban Americans and Nicaraguan immi- 
grants (legal and illegal). 

Most of the families served by the community health center 
are headed by single women. The extended family provides 
essential support in the form of information, childcare, and trans- 
portation services. Many of these women receive public support 
from the programs that are designed to help families with depen- 
dent children, such as the Food Stamp program, Aid to Families 
with Dependent Children (AFDC), and the Women, Infants and 
Children's (WIC) nutritional program. 

The community is plagued with a host of problems including 
high unemployment (particularly among the youth), high rates 
of crime, school dropouts and infant mortality, and an ever- 
increasing epidemic of substance abuse with the associated HIV/ 
AIDS related illnesses. 



368 



Migration Patterns to the Community 

The existence of large numbers of immigrants within these com- 
munities presents complex challenges to the formal social sup- 
port system both in identifying social problems and in providing 
services to meet the needs of the communities. 

Immigrants who enter the country legally or illegally often 
find themselves in an unfriendly host environment. Stress associ- 
ated with major transitions is heightened in the case of immi- 
grants when the host community is not only unfriendly, but 
hostile. Haitians, more than other immigrants to South Florida, 
have experienced a particularly hostile reception. 

Regardless of the ethnicity, when given the choice, immigrants 
typically seek out and settle with family members or in communi- 
ties of other immigrants from their home country. These commu- 
nities provide various kinds of support. Most important, survival 
strategies are quickly shared and information exchanged on how 
to function within the social system and how to access many 
services that are not readily available to long-term residents. 

The perception that recent immigrants receive benefits not 
easily accessed by other groups, especially by American Blacks, 
causes a certain amount of tension among the ethnic /racial com- 
munities. One often hears Black Americans complaining of the 
frequency with which immigrants are allowed services that are 
denied their own ethnic sisters and brothers. These remarks 
perpetuate a perception of societal favoritism to refugees and 
other irnmigrants regarding entitlements and access to formal 
social services. 

Religious Traditions in the Community 

American Black and other ethnic /racial communities place great 
value on religious organizations in the community. Historically, 
the church has served as a primary source of support and infor- 
mation to families. Information that is transmitted to the commu- 
nity from this source is more likely to be received and to be 
believed than that from other sources because the information 
is seen as promoted and sanctioned by trusted religious leaders. 
In general, social programs targeted at the Black American com- 



369 



munity are looked at with suspicion when they do not involve 
the church in some form. 

Examples of this are many. In one case, the Florida State 
Department of Health and Rehabilitative Services (HRS) funded 
an educational program for awareness and prevention of HIV 
infection through churches in the ethnic /racial community dur- 
ing the 1987-88 initiatives to prevent HIV exposure in South 
Florida communities. The Gamble Memorial Church of God in 
Christ in Allapattah, a neighborhood in Miami, and the Duke's 
Temple Church of God in Christ in Liberia, a community in 
Hollywood, Florida, were asked to spearhead the program. Also 
a major Black Baptist college, Florida Memorial College, in Opa 
Locka, Florida, received funds from the Lilly Foundation to edu- 
cate ministers and lay members on how to offer programs in the 
S. church on the prevention of substance abuse and HIV infection. 

Social Support and Information Sharing 

Other ways in which various ethnic groups in South Florida 
support one another and exchange information can be seen in 
the tradition of men assembling at common meeting places to 
play checkers or dominoes, drink, and share life stories. This 
practice is often viewed by middle-class Americans as slothful 
and without any redeeming value. While these gatherings do 
not produce results that are easily measurable, their usefulness 
as a source of social support and information sharing should 
> not be underestimated. 

Neighborhood flea markets serve as a major gathering place 
for members of Black communities in South Florida. Shopping at 
the flea market is a common weekend pastime for men, women, 
young, and old alike. Bargaining and casual conversations are 
the business of the day at these markets. Because of the access 
they provide to members of the community, they have been 
successfully integrated into the outreach efforts of church pro- 
grams on AIDS education and prevention. 

Alcohol-Related Problems in the Black 
American Community 

The Black American communities in South Florida contain a 
disproportionate number of individuals with alcohol depen- 



370 



dency problems. Evidence of this appears in police reports, juve- 
nile justice reports, and the number of admissions to treatment 
programs for substance abuse. 

Black Americans represent 11% of the total population in 
Dade County. However, sixty-seven percent (67%) of the trauma 
cases related to substance intoxication treated at the county hos- 
pital in 1990 involved Black Americans. Fifty-seven percent (57%) 
of all cocaine-exposed babies born in the county in 1990 were 
born to Black American women. In many cases, the users of 
cocaine are also dependent on alcohol (Jackson Memorial Hospi- 
tal Data, 1990). 

In 1987-88, 1,930 infants in the state of Florida were reported 
to HRS as having been exposed to a drug before delivery. By 
1988-89, the number had increased to 4,835. It was projected that 
by 1990-91, more than 6,000 substance-exposed infants would be 
born in the state. These numbers represent only the number of 
reported cases. It is common knowledge in the community that 
private physicians and private hospitals frequently do not report 
this information (Florida State Department of Health and Reha- 
bilitation Services, 1990). 

Part of the problem with alcohol use and abuse within the 
Black American community can be found in the casual attitude 
that prevails regarding alcohol use. Problem drinkers are often 
tolerated and the behavior dismissed as an idiosyncracy rather 
than a medical problem. Sometimes the drinking is seen as symp- 
tomatic of a moral weakness. 

Alcohol use and over-use are common behavior engaged 
in by young men to signify the passage from adolescence to 
adulthood. Typically, the young men who assemble with the 
older men to play checkers try to "hold" their liquor by drinking 
large quantities of alcohol. This behavior is often encouraged by 
the older men. 

A similar behavior occurs in the military services. Young 
soldiers are challenged to drink more than they might ordinarily 
to prove that they have become men. This rite of passage is slowly 
fading, but can still be seen at officers 7 and enlisted soldiers 7 clubs 
during "happy hours" or special social events. 

Another contributor to abusive drinking behaviors is evident 
in the aggressive advertising that is directed at the Black Ameri- 



371 



can communities across America. A quick perusal of Black Amer- 
ican periodicals such as Ebony or Essence reveals many adver- 
tisements with glamorous models who promote drinking as a 
primary ingredient in any successful relationship or career. Bill- 
board advertising continues to plague the community with vari- 
ous forms of alcoholic beverages. 

One frequently hears Black Americans attempting to justify 
abusive drinking habits by insisting that theirs is a natural excess 
stemming from a history of poverty and the inability to enjoy 
some of the benefits of the American "good life." Teetotalers or 
individuals who do not drink alcohol at all are often ostracized 
by the larger ethnic community because of their failure to drink 
socially. Such rationalization only serves to obscure the serious 
issues surrounding alcohol abuse — issues that are being 
addressed, slowly and painstakingly, through the concerted 
efforts of a variety of community health centers. 

The Family Health Center 

Family Health Center (FHC), one such community health center, 
is a comprehensive primary care facility with a state of the art 
alcohol and substance abuse program that is directed by its 
Department of Addictions and Preventive Health Services. The 
Center, the largest ambulatory primary health care center in 
the South Florida area, with five satellites in the major ethnic 
communities, has been in the community for more than twenty- 
three (23) years, providing preventive health care, treatment and 
rehabilitation services to families in need. 

FHC's prevention and treatment program has been available 
to the community for almost as long as the agency has been 
established. Initially, the alcohol treatment program was feder- 
ally funded as the Uhuru Center for the treatment of Alcoholism 
and other Drug Abuse. The goals of the program have been to 
provide prevention education to all of the service users of the 
Center and to offer treatment and continuing rehabilitation and 
support to identified abusers of alcohol and other drugs. 

A review of the Center's historical documents and interviews 
with individuals who have been with the Center in positions of 
responsibility for many years showed that researchers interested 



372 



in the prevention of alcoholism and alcohol abuse had not con- 
tacted the Center to collaborate on a project regarding the preven- 
tion of alcoholism. Professionals who have shown interest in 
the substance abuse program have done so from the treatment 
perspective. The Center has not been requested to participate in 
survey research surrounding alcoholism prevention or treat- 
ment. 

FHC Successes 

While the milieu in which the Center exists continues to reflect 
the great socio-political turmoil that characterizes South Florida 
in general, FHC is pleased with its major achievements and their 
overall impact on the health care status of the service population. 

In 1990-91, preventive health care programs were designed 
primarily for children's health services. These programs included 
an early alcohol and other drug abuse prevention /intervention 
program for elementary school children and a preventive health 
care program for the children in the learning center that was 
established as a support for mothers in the residential treatment 
program for alcohol and other drug abuse. 

Family Health Center also provides prevention education 
for alcohol and other substance abuse for pregnant adolescents 
through the alternative public school for pregnant and post- 
partum students, as well as contracted health services to Florida 
Memorial College students. An aggressive alcoholism prevention 
program is provided to the community through the Department 
of Addictions and Preventive Health Services. 

Although research efforts have not been aggressive, the Cen- 
ter's alcoholism and other drug abuse prevention programs have 
resulted in many pregnant women entering treatment for sub- 
stance abuse behaviors. Those entering and completing treatment 
serve as role models to others on how women in the inner city can 
change a life style that is replete with self-destructive behaviors. 
Therefore, the treatment program has been FHC's best preven- 
tion program for alcoholism and other drug abuse among its 
service users. 

Health data reveal that, when compared to the general popu- 
lation in Miami-Dade County, the users of FHC's services fare 



373 



much better in recovery and rehabilitation from addictive behav- 
iors. For example, none of the Center's prenatal clients delivered 
addicted babies at a time when the number of addicted newborns 
continued to increase in the general service area. This is a major 
accomplishment and can be attributed to the enrollment of all 
pregnant mothers with substance using and abusing behaviors 
into an appropriate treatment program and to providing each 
client with a case manager who can help in finding access to 
necessary services for the women and their families. 



Projects in Process 

The major research institution in the area, the University of 
S Miami, School of Medicine, Department of Psychiatry, included 

the Center in the development of a grant proposal for the funding 
of a prevention treatment for Black youths. The project has yet 
to receive funding. Nevertheless, both agencies are interested in 
developing a collaborative relationship for future projects. The 
inability of the Center to conduct its own research has to do 
with limited resources and its commitment to service, which 
includes education of the community. The lack of research profes- 
sionals on the Center staff has also impeded the research process. 
Even when professionals with appropriate preparation and inter- 
est have been on staff at the Center, service has always taken 
precedence over research because the funding of the service is 
dependent upon its actual provision and documentation. 

In 1992, the Center was awarded a Robert Wood Johnson 
Foundation grant to conduct an evaluative study of the residen- 
tial substance abuse treatment program and its relationship to 
the childcare program. This represents the first such funded 
research project. The project is still evaluating the treatment 
component of the program. Results of the findings on prevention 
will not be known for many years, and the childcare component 
of the project is committed to following the children until they 
reach grade school. Beyond the first grade, no plans have been 
made for following the children who are now in the childcare pro- 
gram. 



374 



Building Collaborative 
Relationships 

In this section, several topics are examined that are about build- 
ing collaborative relationships between researchers and commu- 
nity members: (1) the socio-cultural model of alcohol abuse pre- 
vention; (2) the role of the "culture broker"; (3) barriers to collabo- 
rative relationships; (4) the public use of language; (5) the 
perceived attitudes of researchers; and (6) the publication of 
research findings. 

The Socio-cultural Model 

There are many models used by researchers engaged in alcohol 
abuse prevention research. Tuchfeld and Marcus (1984), for 
example, reviewed three prevention models: (1) social-structural, 
(2) public health, and (3) socio-cultural. For the exploration of 
collaborative relationships, however, application of the socio- 
cultural model is most appropriate. The model implies that alco- 
hol abuse can be prevented when social activities are used to 
introduce and control the drinking of alcohol, especially when 
introduced at an early age. Furthermore, this model also suggests 
that by using a trusted public figure to promote responsible 
drinking, the prevention of alcohol abuse can be effected. In 
other words, it supposes that the specific culture poses some 
influence on the development or the prevention of alcohol- 
related problems. 

Researchers who are interested in studying prevention strate- 
gies in Black American communities can best serve the commu- 
nity by considering the specific factors involved in the socio- 
cultural model. Notwithstanding, the other models also present 
alternate frameworks for study. However, when the cultural 
group is specifically identified, it is because of the uniqueness 
of the culture and the different components of the culture that 
one looks to such a model to provide explanations and under- 
standing of antecedents and consequences of behaviors. 

Black American culture (more recently called "African- 
American culture") is as diverse as "American Culture." It is 



375 



helpful and appropriate to use anthropological concepts to 
understand the emic views of the communities being studied. 
Each community has a culture of its own. There may be some 
underlying connections based on the common African heritage. 
These, however, may range from skin color only to a shared 
appreciation of the religious institutions that have been tradi- 
tional sources of strength and support within the Black commu- 
nity. 

The Role of the "Culture Broker" 

Researchers wanting to be effective in the Black American com- 
munities will involve members of the cultural group in any 
studies that are undertaken to look at alcohol abuse prevention 
^ interventions. These individuals must understand cultural phe- 

|5 nomena, culturally defined antecedents and consequences of the 

behaviors under study, as well as other nuances of the culture. 
This individual, sometimes called a ' 'culture broker," also under- 
stands the larger scientific community and can communicate 
with both audiences (Weidman, 1985). A "confidante," on the 
other hand, is a member of the cultural group who can help with 
gaining entree into a society or the collection and interpretation 
of cultural phenomena, but may not appreciate the scientific 
requirements for accuracy and, therefore, may "interpret" data 
in a biased way. 

Barriers to Effective Collaboration 

Collaborative arrangements can be established when the 
researcher contacts respected individuals from the community. 
These individuals can direct the researcher to data sources, either 
to begin new studies or to supplement existing studies. Too 
often projects are begun but not completed because of decreased 
interest or lack of commitment by the individuals involved. Stud- 
ies may have begun before the investigator had an adequate 
understanding of the environment and the cultural group 
being studied. 

Just as collaboration between the investigator and members 
of the community enhances a study, failure to collaborate may 



376 



, .; 



create barriers and inconclusive results. Studies performed with- 
out the kind of trust provided by the culture broker often lead 
to pro forma responses in which subjects give to the researcher 
what they believe is expected, whether accurate or not. 

Oetting and Beauvais (1991) identified three types of failure 
regarding alcoholism prevention projects: (1) failure to initiate, 
(2) failure to be effective, and (3) failure to thrive. These three 
types of failure are very descriptive of how prevention interven- 
tions can be unsuccessful. Inadequate planning, inadequate 
funding, or failure to include members of the community as 
part of the research design often contribute to failure to initiate. 
Failure to be effective is evident when a program is carried out 
but fails to realize its stated goals. Such programs may answer 
some questions but fail in the primary objective of the study. 
Failure to thrive is manifested when programs that begin with 
ample support from the target community, the scientific commu- 
nity, and the general public lose the attention and commitment 
of these constituencies over time. 

Language as a Barrier 

An important issue that is often raised in the Dade County 
community is that of an "official" language. Sensitive to the 
increase in immigration, voters in that county declared English 
to be "the official language of Dade County." This issue was 
very divisive in the community since it seemed to achieve little in 
any real sense, but rather exacerbated barriers to social services. 
Language is a formidable barrier under any circumstances, but 
particularly so when the language spoken by the service seeker 
is different from that of the service provider. The "English Only" 
law was most recently repealed by the Dade County Commis- 
sioners. 

The barrier of language can be overcome most easily when 
the researcher learns the language of the client population. This 
is not always possible. Regardless, members of the target group 
should be identified as translators and interpreters as well as 
research assistants, confidantes, and culture brokers. 

In the Black American community, the language spoken is 
English. Despite differences in dialect, the community members 



377 



expect outsiders to address them in standard English. Research- 
ers are well advised to use terminology that the average person 
can understand. The use of street vernacular and "ghettoese" is 
not expected or even recommended for establishing rapport or 
gaining confidence for those researchers spending a limited 
amount of time in a particular community. Outsiders who try 
too hard to assimilate may find themselves raising suspicions 
as to their motives and intentions. 

On the other hand, a researcher who has worked in the 
community for some length of time may be expected to incorpo- 
rate some element of that community's values, mores and lan- 
guage. While certain individuals may have difficulty mastering 
a second language, it is imperative that researchers avoid the 
air of superiority so often seen among White American scholars, 
fl; particularly around the issue of language. 



Perceived Attitudes of Some Researchers 

Still another barrier to building collaborative prevention research 
projects in the community has to do with the preconceived beliefs 
of researchers, many of whom are entering Black American com- 
munities for the first time. Some approach research as if provid- 
ing a missionary service to a pitiable humankind. This kind of 
condescension does little to engender a spirit of cooperation. 
Others bring with them an obsessive concern about crime, seem- 
ing to equate all Black males with violence and criminality. 

Still others offer grand plans for treatment programs with 
little consideration for prevention programs. This is not only 
true in alcohol prevention, but also with other health care issues 
as well. In each of these instances, researchers take their inspira- 
tion less from the community they are studying than from their 
own preconceived notions of what the community may need. 

The Publication of Research Results 

Last, the paucity of published study results among alcohol abuse 
prevention programs poses a serious barrier to progress. More 
often than not, prevention programs do not have the results 
printed, so that the efficacy of the projects remains unclear. The 
publication of findings is needed to determine success or failure. 



378 



The Family Health Center has sponsored an alcohol and other 
drug abuse prevention /intervention program with elementary 
school children for more than eight years. This collaborative 
effort with the county school board appears to have been success- 
ful, and the school board has entered collaborative relationships 
with other community agencies to establish four more of the 
programs in other schools. 

At the same time, requests for evaluation of the program 
regarding prevention of substance use /abuse and participation 
by parents in the children's educational program have gone 
unanswered. This, quite clearly, is because the results do not 
exist. The program managers emphasized prevention at the 
expense of evaluation. Evaluation and analysis of outcome crite- 
ria are an essential part of any prevention program, and their 
importance cannot be underestimated. 

Conclusion 

Universities and other research agencies can and should create 
relationships with public health agencies and other community- 
based organizations to continue to study alcohol-related prob- 
lems within the Black American community. Ideally, the 
researcher initiates this relationship because of interest, research 
expertise, and access to resources. 

Although it is the researcher who initiates the relationship, 
it should be conceived of as collaborative so that the investigators 
and community organizations are viewed as equal partners in the 
project. Too often academic researchers use community-based 
organizations without ever acknowledging the contributions of 
these agencies or giving them appropriate credit. Having had bad 
experiences, many of these agencies refrain from participating in 
studies that could well benefit their service users. Mutual respect 
is the necessary antidote and will go a long way in rectifying 
this dilemma. 

Collaborative relationships are more likely to be successful 
when the orientation and the conceptual framework upon which 
a study is designed fit the philosophy and orientation of the 
community-based organization. For example, a study focusing 



379 



on genetic determinants of alcoholism is destined to fail in a 
community church or health center. Biological studies are best 
carried out in large medical centers or acute care facilities. Socio- 
logical and behavioral studies, by contrast, are well suited to the 
community health care setting. 

Grant and Johnstone (1990) proposed that an interdisciplin- 
ary approach to the study of alcoholism and alcohol abuse was 
critical in moving forward in prevention intervention. Finding 
the appropriate balance in this interdisciplinary approach (some- 
where between qualitative and quantitative research, between 
biological and sociological investigation) remains the challenge 
to researchers studying alcoholism and alcohol abuse in the Black 
community. 

I References 

N 

Grant, M., and Johnstone, B.M. Research priorities for drug and alcohol studies: 

The next 25 years. International Journal of Addictions, 25(2A):201-219, 1990. 

Falco, M., The Making of a Drug-Free America: Programs That Work. N.Y.: Times 
Books, 1992. 

Oetting, E.R., and Beauvais, F. Critical incidents: Failure in prevention. Interna- 
tional Journal of the Addictions, 26(7): 797-820, 1991. 

Tuchheld, B.S., and Marcus, S.H. Social models of prevention in alcoholism. 
In: Matarazzo, J.D et al., eds. Behavioral Health, N.Y.: Wiley and Sons, 1984. 

Alcohol and Other Drugs. Healthy People 2000, USDHHS Publication No. (PHS) 
91-50212, 1991, pp. 164-184. 

Weidman, H. Alternate health care systems in and by migrant groups. Paper 
presented at the Annual Conference of the National Council on International 
Health, Miami, FL, 1985. 



380 



17 



Comments on Alcohol 

Prevention 
Research in Black American 

Communities 



Janet L Mitchell 



Yesterday, Dr. Langton reminded me that when she con- 
tacted me about this conference, I suggested she might want to 
conceptualize the conference differently. I suggested that 
researchers did not all sit at academic institutions. One idea that 
came across yesterday, and hopefully was dispelled by today's 
first two speakers, is that being at an academic institution does 
not legitimize you as a researcher. You can be in the "commu- 
nity" and be a researcher. Drs. Brown and Seabrook exemplify 
that. 

I would like to remind Dr. Brown about our first collabora- 
tion. When I returned to New York in 1988, having spent five 
years in Boston, he and I set out to submit a grant to NIDA. 
Some of you are familiar with Dr. Brown's credentials. Dr. Brown 
is the Vice President for Medical and Research Affairs for a large 
minority-owned methadone maintenance treatment program in 
this country, the Addiction Research and Treatment Corporation 
(ARTC). He has a part-time job at Harlem Hospital Center that 
provides him an academic appointment at Columbia University, 
College of Physicians and Surgeons. He spends most of his time 



381 



K 



at ARTC. When I returned to Harlem Hospital (I had trained at 
Harlem Hospital in OB/GYN) to take over the largest prenatal 
program for substance-abusing pregnant women in the City of 
New York, I also was given a Columbia University appointment. 
However, all of my time and all of my work was at Harlem 
Hospital. I have been doing work in substance abuse and preg- 
nancy for many years. 

Dr. Brown and I wrote a grant in response to an RFP from 
NIDA to study the impact of drug abuse on pregnancy. One 
comment on the pink sheet (the summary of the critique of our 
proposal) stated that the principal investigators did not have a 
clear understanding of the problem or the population. We both 
had a long history of successfully providing services to the tar- 
geted population. We both worked in communities with great 
numbers of the targeted population. Could it have been because 
s we did not sit at an ' 'academic institution 7 ' that the review panel 

felt we did not have the needed skills to carry out the project? 
Could it have been because our perception of the problem and 
our approach offered an approach not deemed acceptable by the 
reviewers? We were, in fact, community-based in our orientation. 

"Who" is researching "whose" community? Every speaker 
yesterday was a researcher. Perspectives, however, maybe differ- 
ent depending on whether one is based at an academic institution 
or in a community-based organization (CBO). 

Those based at CBOs (Harlem Hospital Center is considered 
a CBO) are well acquainted with the problems to which Dr. 
Seabrook referred in her paper. The needs of community-based 
researchers are different. If you are reviewing a grant from a 
CBO that asks for a full-time secretary, it is because there is no 
one to answer our telephone. In fact, there is an answering 
machine on my phone so that it does not go unanswered. An 
answering machine that I bought out of my pocket. If there are 
typographical errors, it is because we do our own typing. With 
no secretary and little to no other support, grants are written 
after work and on weekends, often into the early hours of the 
morning. So if you wrote "T-O-O" but intended "T-W-O," spell- 
check (if you have access to a computer) would not alert you. 
Few community-based researchers have secretaries or other col- 



382 



leagues to help with rewriting and editing. Despite the many 
problems with being a community-based researcher, several 
excellent ones exist, and some of them are attending this meeting. 

Let's now focus a bit more on "community." Just as with 
other communities, the African- American community is not 
monolithic. It is important to acknowledge this diversity, as Dr. 
Seabrooks discussed "who is the community" and "what com- 
munity" has been researched. For the most part, the "commu- 
nity" that has been researched and written about is known in 
our vernacular as the "Hood." Essentially these are communities 
of color that are predominantly poor and urban. Unfortunately, 
the findings are often extrapolated to myself, Dr. Brown, and 
Dr. Seabrooks. I do not know where Dr. Seabrooks lives, but Dr. 
Brown does not live in the "Hood" and neither do I. 

Unfortunately, almost all research on African Americans is 
basically done in impoverished neighborhoods. Often the socio- 
political-economic climate makes it difficult to tease out what 
the real variables are when one attempts to evaluate or interpret 
data from these studies. Is it poverty? Is it ethnicity? Is it culture? 

My interest in substance abuse in pregnancy grew out of 
my concern with the high infant and maternal morbidity and 
mortality rates in the African American community. The research 
in this area has also focused mainly on poor communities. The 
inter-relationships of economics, political structure and societal 
problems make it difficult to find causal effects. The Centers 
for Disease Contrors Division of Reproductive Health, with an 
African American researcher, Dr. Diane Rowley, as division 
head, decided that one way of teasing apart these variables might 
be to look at a subpopulation of African American women. That 
subpopulation was a population of college-educated Black 
women, married to college-educated Black men. The infant mor- 
tality rate of this subpopulation was compared to that of college- 
educated White women married to college-educated White men. 

Two interesting points emerged. One, the gap in infant mor- 
tality still existed, but more than 80 percent of the gap could be 
accounted for by the rates of preterm labor and delivery. For 
term infants, there was no gap. We know many of the causes of 
preterm labor. We know that both physical and psychological/ 
emotional stress can lead to preterm labor and delivery. 



383 



Given the decades and money spent on trying to narrow 
the infant mortality gap, it is surprising that this approach had 
not been considered earlier. This association would probably not 
have been found had we not looked at a subpopulation who 
were more like the ' 'White norm" than the "Hood." Interventions 
and prevention strategies can now be focused. That stress can 
produce physiological effects is well known for other diseases, 
notably cardiovascular diseases. One theory that attempts to 
explain the high rates of hypertension among African American 
males is called the John Henry-ism syndrome. It suggests that 
the stress of needing to "prove" oneself to work harder just to be 
accepted, creates high levels of internalized stress that manifests 
itself physiologically by an increase in blood pressure. In more 
simple terms, it is the stress of oppression. 

While oppression has been discussed at this conference, the 
more applicable term, racism, has not. Certain stresses are inter- 
nalized by populations who have been oppressed simply by the 
way they look — the color of their skin. I would be very interested 
to know why Dr. Seabrooks left her associate professorship to 
work in the community. If she is anything like me, I spend a 
few years in the White world and submit myself to all the stresses 
and strains of being African American and female in a White 
and usually male-dominated environment. When I feel that I 
have had enough of that type of stress, I go back to the Black 
community and I deal with that stress — a different kind of 
stress — but equally stressful. I move back and forth for my own 
sanity. The types of stresses that occur when I am in a White 
world are different from the types of stresses that I encounter 
when working in my community. 

Additionally, we need to understand that sometimes, unbe- 
knownst to researchers, their perception of what it is they want 
to find has little to do with reality. If African Americans are so 
deficient (we talked about, deficit research yesterday), then why 
look at prevention? If we are serious about the prevention of 
alcoholism and the abuse of other drugs, why not look at that 
segment of the community that does not have a problem? Should 
we not know what keeps those members of the same community 
from taking that first drink? Why are we more comfortable 



384 



when dealing with only the pathology of African American com- 
munities? Could it be because that is what gets published and 
feeds into the stereotypes that this country wants to perpetuate? 
Is it these stereotypes that allowed the jurors in L.A. to think 
that Rodney King deserved the beating he got? Deficit research 
perpetuates the stereotypes. 

Most community-based researchers do not ascribe to the 
deficit research model. This is but another of the difficulties 
community-based ethnic /racial researchers have in getting 
papers accepted for publication, in being even accepted as a 
researcher. 

There is no reason to distinguish "community researchers" 
from "academic researchers/ ' We are all researchers. The only 
difference may be in the way in which we interpret the data or 
in the way in which we approach a problem. That is why we 
are here today discussing "community researchers," the "com- 
munity response," the "community approach." 

I was part of a HIV/ AIDS panel last week, discussing charac- 
teristics associated with high risk behaviors. In a survey done 
by researchers from the CDC, religious affiliation was a marker 
for decreased rates of risk taking behaviors in White females but 
not in Black females. The presenter remarked that he and his 
colleagues had no explanation for this difference. The explana- 
tion was apparent to every African American in that room. Our 
culture is one in which most of us are exposed to an organized 
religion early in our lives. Nearly every one of us started out in 
Sunday School. Most of us were baptized as children, so almost 
all of us have a "religious affiliation." The question not asked 
was about those who continue to attend religious services. That 
was the more appropriate question to ask. Asking the "wrong 
question" may not only provide you wrong information but also 
may yield you no information. You seldom get past five years 
old without being baptized as an African American. It does not 
mean that you now go to church as a 30-year-old, but it does 
mean you have a religious affiliation. Most ethnic/racial 
researchers who grew up in an African American culture would 
have foreseen the problems with that question before doing the 
survey and would have explained the differences in the results 
between Blacks and Whites. 



385 



If this meeting is about prevention of alcoholism in the Black 
community, then we need to know what keeps one from taking 
that first drink. We need to focus on the populations in communi- 
ties (subpopulations) that have lower rates of the problems we 
find of interest, to understand why they have lower rates. 

This is but one reason ethnic/racial researchers who are "of 
the culture" make research better. We can look at a questionnaire 
and explain why a question may not yield the information 
desired. We can explain why the question may have worked 
well in other populations but because of subtleties and nuances 
in language and culture it may need to be reworded. 

If we are to approach prevention from the more positive 
perspective that seeks to find out why people do not initiate high- 
risk behavior, or why they cease indulging in that high-risk 
behavior, then we must not only change the philosophy of fund- 
ing agencies but also the composition of review committees 
(IRGs) that determine what research is funded. The preference 
of most agencies to have grants reviewed by persons "at the 
associate professor level" almost by definition excludes those of 
us who are community-based. You would be surprised how 
many grants would not get funded or how many research meth- 
ods that looked wonderful on paper would be torn apart when 
people who actually are in those communities tell you why this 
will not work. 

The under-representation of minorities in AIDS clinical trials 
is a perfect example of noted academicians at highly respected 
academic institutions being funded but unsuccessful in recruiting 
minorities. Most of these institutions had no track record with 
providing service in a respectful way to minorities. Many were 
even distrusted by the very communities from which they pro- 
posed to recruit. Not having minorities from these communities 
on review committees meant there was no one who raised ques- 
tions about the feasibility of these institutions accomplishing 
their stated goals. The National Institute of Allergy and Infectious 
Disease (NIAID) funded institutions that historically had turned 
their backs on the populations they now wanted to study. The 
thought was that if these institutions received money, opened 
their research doors ,and offered clinical trials, then ethnic /racial 



386 



groups would get involved in the studies. What was not under- 
stood or represented on review committees was the perspective 
of the communities, who responded by saying, Why should I 
now go to an institution that always sent me to their emergency 
room (or gave me carfare to go to the public facility) but did 
not want to see me come through their front door? 

This costly mistake, fiscally and politically, changed the way 
MAID did business. MAID opened its review process to include 
persons from non-traditional settings with a greater emphasis 
on knowledge and experience with ' 'hard-to-reach populations" 
and less on traditional academic credentials. Consequently, 
MAID significantly increased the numbers of ethnic /racial and 
community-based researchers involved at all levels, not just the 
review process. Now, when grants are reviewed from institutions 
that claim they can recruit and retain certain populations into 
studies, there are people on the IRG who say, "Tell us what your 
history is with serving this population," "Convince me that you 
can deliver." 

As you contemplate an agenda for research in communities 
of color, understand that success is dependent on "how" you 
proceed and "who" are your partners. You may need to not 
only rewrite your RFP, but to reconfigure your IRGs. You need 
to examine the philosophy of the agency and the philosophy 
of the members of the agency responsible for articulating that 
philosophy and allow for the fact that it may be biased. 

Additionally, keep in mind that most African American com- 
munities have a historical distrust of all researchers. They come 
in, take things out of the community, leave nothing in return, 
and misinterpret what is actually going on. Do not expect com- 
munities to accept you with open arms because you think your 
intentions are honorable. Remember, they did not ask to be 
studied! 

It took the crisis of HIV/AIDS to get MH and MAID to 
understand that if you really want to get the answers from com- 
munities of color, you do have to leave something behind. In the 
case of HIV /AIDS, it was access to clinical care. The traditional 
researcher's concern about "polluting" results when you mix 
research with clinical care was unjustifiable in communities that 



387 



s 



historically lacked access to basic health care. You need to enter 
into partnership with the communities from which you are trying 
to get information. You need to gain their trust. 

Many people around the research table still have some learn- 
ing and growing to do. Researchers need to acknowledge and 
accept the following: 

• Understand that in African American communities, there 
is still the fear of genocide and of being used as guinea pigs. 

• There is the perception that you, as researchers, are taking 
from the communities and not leaving anything. That the 
community is a "means to an end" to benefit your career. 
That neither you nor your research findings benefit the 
community in any way that the community can document. 

• There is also the fear that the basis of your prevention 
programs is "I (the researcher) will tell you what I think 
you should do and how you should do it (my design, my 
theory, my hidden agenda?)," as opposed to "Tell me 
how you think I can help you." HIV/AIDS prevention 
programs targeted to ethnic /racial groups originally took 
that approach. Essentially, prevention messages that 
worked with gay White males and reduced their high-risk 
behaviors were modified, slightly, and translated into other 
languages. The faces were made to look like the ethnic/ 
racial group. The theory was "if it worked with gay White 
males, it should work with other populations." It did not! 

You have before you an opportunity to learn from the mis- 
takes of others and to forge alliances with communities of color 
as never before. If you take to heart what has been said here 
today by Drs. Brown, Seabrooks and others in the audience, the 
chances of success in finding useful information for the preven- 
tion of alcoholism and other drug abuse in the African American 
community will be greatly enhanced. 



388 



18 



Alcohol Abuse Prevention 

Research in Asian American 

and Pacific Islander 

Communities 



Kiyoko M. Parrish 



Introduction 

Asian Americans are descendants of Chinese, Asian Indians, 
Filipinos, Japanese, Koreans, and Southeast Asians (for example, 
Laotian, Cambodian, Malaysians, Thai, Vietnamese). Pacific 
Islanders are Polynesian (for example, Hawaiian, Samoan, Ton- 
gan) and Micronesian (for example, Guamanian, Melanesian). 
Asian Americans and Pacific Islanders are linguistically and cul- 
turally diverse populations. However, in previous research the 
heterogeneity of Asian Americans has not been addressed. In 
some research, these groups are aggregated into Orientals (Welte 
and Barns, 1987), or Asians (Maddahian et al., 1985). In recent 
years, more attention has been paid to the differences among 



The author thanks Drs. Janice Rabkin, Diana Farrow, and Phyllis Langton for 
their editorial assistance. 



389 



selected Asian American populations on the West Coast (Kitano 
and Chi, 1986-1987). However, even within the same country 
of origin, there are culturally distinct ethnic groups, such as 
ethnic Chinese among Vietnamese, and Hmong from highlands 
Laos among Laotians. 

This paper first describes a brief historical background of 
Asian American and Pacific Islander immigration, and provides 
a demographic profile to give a better understanding of the 
heterogeneity and complexity of Asian American and Pacific 
Islander populations. After a review of the genetic susceptibility 
to alcohol among Asian Americans, the differences in drinking 
practices among Asian American populations are examined and 
drinking problem prevention research is discussed. 

Historical Background of Asian 
American Immigration 

Immigrants generally do not represent a random sample of popu- 
lations from their native countries. Even within the same country 
of origin, reasons for immigration change over time, and so does 
the socioeconomic status of the immigrants who enter the United 
States. Therefore, immigrants from the same country may not 
necessarily share cultural norms and drinking practices. 

From the beginning of this century to 1980, approximately 
three million Asians immigrated to the United States (Arnold, 
et al., 1987). Chinese were the first Asians to immigrate in large 
numbers to the United States, escaping economic depression, 
political unrest, and a series of natural disasters in China. From 
1854 to 1883, nearly 300,000 Chinese, mainly from Southern 
China, immigrated to the booming West Coast to work on the 
railroads and mines, in agriculture, and in personal services. 
Their willingness to work for low wages resulted in conflict with 
labor unions during a recession, and the Chinese Exclusion Act 
was passed in 1882 to bar Chinese immigration to the United 
States. 

After Chinese were barred from immigrating to the United 
States, Japanese were brought to work on sugar cane plantations 
in Hawaii and the fruit and vegetable farms in California. Japa- 



390 



nese immigrants followed the same fate as Chinese. A series of 
immigration laws were passed to limit the number of immigrants 
from Asia, including the Gentlemen's Agreement in 1907, and 
the National Origins Act in 1924 (Arnold, et al., 1987). Until the 
McCarran- Walter Act was passed in 1952 liberalizing immigra- 
tion for Asian immigrants, the number of Asian immigrants 
was restricted. In 1965, the National Origin quota system was 
abolished, which opened the door for Asian immigrants (Arnold, 
et al., 1987). In that year, 17,000 Asians entered the United States. 
The flow of Asian immigrants has grown rapidly since then. By 
1978, Asia had become the largest source of immigrants to the 
United States, surpassing North and Central America. 

Approximately 90% of Asian immigration was based on fam- 
ily preference — a priority status to unite spouses, unmarried 
sons and daughters of permanent resident aliens, and their chil- 
dren. The percentage of immigrants entering the United States 
under occupational preference varied greatly over time even 
within the same country of origin. Based on this category, 
between 1970 and 1974, more than 50% of Filipinos who immi- 
grated to the United States were professionals or highly skilled 
workers. By 1980, this percentage had dropped to 1.6% and then 
rebounded to 20% in the mid 1980s (Arnold, et al, 1987). 

Pacific Islanders 

The South Pacific consists of some 23 states, in which approxi- 
mately 1,000 languages are spoken. This huge territory encom- 
passes 30 million square kilometers of ocean and 550,000 square 
kilometers of land area and reflects cultural and economic diver- 
sity (Connell, 1987). The 1980 census was the first one to count 
Pacific Islanders in the United States, and 87,320 Pacific Islanders 
(excluding Hawaiians) were enumerated. Samoans were the 
largest group, accounting for 45% of Pacific Islanders, followed 
by Guamanians (35%) and Tongans (7%) (Xenos, et al, 1987). 
American Samoa is an unincorporated territory and is adminis- 
tered by the U.S. Department of the Interior. Western Samoa is 
not a U.S. territory; however, Western Samoans can manage to 
enter the U.S. by way of American Samoa. Guam is a U.S. terri- 
tory, and in 1951 Guamanians were granted U.S. citizenship. 



391 



Enlistment for U.S. military service is a favored option among 
young Samoans and Guamanians, offering an opportunity for 
travel, training, and a higher income by Islander standards. 
Younger generations of these groups enter the United States for 
higher education, assisted by the federal Pell Grant program 
(Xenos, et al., 1987). 

Southeast Asian Refugees 

Refugees from Southeast Asia added another dimension to Asian 
immigration history. From the end of the Vietnam war in April 
1975 to December 1975, approximately 130,000 Southeast Asian 
refugees (95% Vietnamese, the rest mostly Kampucheans) 
entered the United States (Gordon 1987). They were mostly from 
urban areas and belonged to elite classes (Uba, 1992). In 1980, a 
second wave of Southeast Asian refugees arrived due to eco- 
nomic hardship and political oppression in their native countries. 
This second wave included ethnic Chinese in Vietnam and 
Hmong from highlands Laos (Gordon, 1987). These refugees 
were more likely to be from rural areas, were much less educated, 
and were less proficient in English than the first wave refugees 
(Uba, 1992). 

Geographic Distribution 

Although well over 50% of Asian immigrants reside on the West 
Coast, the distribution of Asian Americans shows considerable 
variation in geographic locale. Over 80% of Japanese Americans 
live on the West Coast, while only 19% of Asian Indians live in 
the West, with the highest concentration in the Northeast (34.3%). 
Southeast Asian refugees are more evenly spread throughout 
the United States. This is in part because the United States gov- 
ernment has tried to spread the impact of refugees to various 
regions of the United States to ease the transition to a new life 
(Gordon, 1987). Nonetheless, Vietnamese tend to cluster in the 
West and in the South, and Laotians tend to settle in the Western 
and North Central states (Bouvier and Agresta, 1987). Pacific 
Islanders are concentrated in urban areas on the West Coast and 
in Hawaii (Xenos, et al., 1987). 



392 



Socioeconomic Status of Asian 
Americans 

Higher educational attainment is associated with lower absten- 
tion rates among Asian American populations (Klatsky and Arm- 
strong, 1991). Observed differences in drinking practices among 
Asian American populations can be partially explained by the 
differences in socioeconomic status among Asian Americans. 

Compared with the other ethnic minority groups, namely 
Hispanic and African Americans, Asian Americans have higher 
income levels overall. Figure 18-1 shows the percentage of fami- 
lies below the Federal Poverty Level in 1980. The percentage of 
families below the Federal Poverty Level for Japanese, Filipinos, 
and Asian Indians was comparable to or slightly higher than 
that for U.S. Whites, while the percentage of Vietnamese families 
below the poverty level was five times as high as that for the 
U.S. Whites. 

As educational attainment and command of English differ 
among Asian Americans, the type of occupations in which they 
engage also varies. Figure 18-2 shows the percentage distribution 
of occupational categories among men in 1980. The most presti- 



40% 
35% 
30°/c 
25°/c 
20°/c 
15% 
10% 

5% - 

0% 



US WHITES 



\ 



Japanese 



Filipinos Asian Indians Chinese 



Koreans 



Vietnamese 



Figure 18-1. Percentage of Families Below Poverty Among 
Selected Asian American Groups, 1980 Census 

Source: Xenos, et al., 1987 



393 







k---- 



Caucasian Japanese Chinese Filipino Korean Asian Indian V ietnamese 



| | Others 

I | Operators, fabricators, laborers 

Precision production, craft, repair 



I I Service 



I I Sales 

I I Professional 

| Executive, administrative, managerial 



Figure 18-2. Occupational Categories for Males by 
Ethnicity, 1980 Census 

Source: Xenos, et al., 1987 



gious and best paid United States census occupational categories 
are: (1) executive, adrninistrative, and managerial, and (2) profes- 
sional specialty. In 1980, approximately 23% of U.S. Caucasian 
men were in these two categories. Over 56% of Asian Indian 
men were in these occupations, whereas only 15% of Vietnamese 
men were in these higher paid occupations. Chinese, Japanese, 
and Korean men also tended to have prestigious occupations. 
Women showed a similar pattern, although percentages in these 
two prestigious occupations are lower than they are for men in 
all groups except Filipinos (Xenos, et al., 1987). 

Southeast Asian refugees suffer from high unemployment 
rates due to poor English skills and a lack of appropriate work 
experience for the U.S. job market. The unemployment rate for 
Southeast Asian refugees was 86% soon after entering the United 
States. The rate remained at 30% after four years of residency. 
However, if two or more household members were employed, 
only 7% of the households were below the poverty level (Xenos, 
et al, 1987). 

Pacific Islanders tend to have lower income and educational 
attainment than the national average. Per capita income for 



394 



Samoans is only 49% of the national average, and it is 76% for 
Guamanians. Similarly, 28% of Samoan families were below the 
poverty level in 1980, compared with 12% of Guamanians, and 
10% for the nation as a whole. Samoans are overrepresented in 
service jobs and as operators or laborers. Although the percent- 
age of high school graduates for these two groups were close to 
the national average, the percentage of college graduates was 
about half the national average. In recent years, younger genera- 
tions of Pacific Islanders came to the United States for higher 
education (Xenos, et al., 1987). This trend will change the socio- 
economic status of Pacific Islander immigrants living in the 
United States in the future. 

Asian American Population 
Projections 

Figure 18-3 shows the projected number of Asian Americans. 
By 2030, Vietnamese and Filipinos will become the largest Asian 
American minority groups, followed by Koreans and Chinese, 
unless significant changes in irnrnigration laws take place (Xenos, 



20,000,000 

18,000,000 

16,000,000 

14,000,000 

12,000,000 

10,000,000 

8,000,000 

6,000,000 

4,000,000 

2,000,000 













































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-- 




■H. — 



























1980 



1990 



2000 
Y E 



2010 

A R 



2020 



2030 



] Vietnamese 
] Laotian 
J Korean 
J Kampuchean 
] Japanese 
] Indian 

Filipino 

Chinese 



Figure 18-3. Projected Asian American Populations in the 
United States 

Source: Bouvier & Agresta 1987 



395 



et al., 1987). Japanese, once the largest Asian American group, 
will become a minority Asian American group due to small 
numbers of Japanese immigrants in recent years. The number 
of Pacific Islander immigrants is expected to grow as the Islanders 
seek higher standards of living in the United States (Xenos, et 
al., 1987). 

The implications for a large influx of immigrants and geo- 
graphical clustering of the immigrants are twofold: (1) the pres- 
sure to assimilate to the U.S. culture is less and (2) immigrants 
can better maintain their culture and drinking habits. Conse- 
quently they have less exposure to the U.S. mainstream culture. 
This is truer for Chinese Americans who were born, raised, and 
work in Chinatown San Francisco, for example, than for Chinese 
Americans who live in suburbs and work in organizations where 
very few Chinese Americans work. 

Before comparing the drinking practices and alcohol-related 
problems of Asian Americans and the U.S. population, the case 
for genetic susceptibility to alcohol among the Asian population 
is reviewed. In particular, the review focuses on our knowledge 
of the flushing response, which drew considerable attention in 
recent years for its potential effects to prevent heavy drinking. 

Genetic Susceptibility to Alcohol 

There are two major enzymes to metabolize ethanol: alcohol 
dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH2). 
The inactive form of mitochondrial ALDH2 isozyme is found 
among Asian populations (Suddendorf, 1989) and is associated 
with flushing reactions. Flushing reactions include facial flush- 
ing, nausea, headache, rush, itchiness, dizziness, drowsiness, 
anxiousness, perspiration, rapid heartbeat, weakness, and flush- 
ing elsewhere on the body; facial flushing is the most common 
reaction (Clark, 1988). These unpleasant reactions have been 
thought to deter individuals from heavy drinking and to explain 
low alcohol consumption among Asians. A study of facial flush- 
ing among Japanese in Japan and Japanese Americans in Oahu, 
Hawaii and Santa Clara, California, showed that respondents 
who reported flushing always after ingestion of alcohol were 
less likely to be heavy drinkers than those who did not. However, 
among individuals who reported facial flushing, the proportion 



396 



of heavy drinkers was higher in Japan than in Japanese Ameri- 
cans in Hawaii or Santa Clara (NIAAA and JNIA 1991), suggest- 
ing the importance of cultural factors in alcohol consumption. 
In a culture where pressure to drink heavily is high, being a 
flusher does not seem to prevent individuals from heavy alcohol 
consumption. 

Harada, et al.(1982) reported that individuals with the inac- 
tive ALDH2 isozyme were substantially underrepresented in 
alcoholics compared with their nonalcoholic controls. Among 
alcoholics less than 3% had the inactive ALDH2 isozyme, com- 
pared with 41% of nonalcoholic controls. Goedde, et al. found 
great variation in the prevalence of the inactive ALDH2 isozyme 
among Asians (range: 8%-50%) and Native Americans (range: 
4%-43%) (Goedde, et al. 1985). Even among Chinese, the preva- 
lence varied from a low of 29.7% among Mongolians to a high 
of 50% among Han (Goedde, et al, 1984). 

Genetic studies on the inactive ALDH2 isozyme are ongoing. 
Investigations at the National Institute on Alcoholism in Japan 
on the subtypes of inactive ALDH2 isozymes report that the 
distribution of subtypes of inactive ALDH2 isozymes between 
alcoholics and normal controls differs significantly, and some 
inactive ALDH2 isozymes may not be protective against alcohol- 
ism (Personal communication, Higuchi, 1993). 

In recent years, the genetic aspect of alcoholism has received 
considerable attention. However, this emphasis may undermine 
the importance of social factors in drinking. In Islamic culture, 
where the use of alcohol is discouraged and access to alcohol 
is very limited, even if an individual is genetically prone to 
alcoholism, the risk of becoming alcoholic remains very low. 

The Drinking Practices and Alcohol- 
Related Problems of Asian 
Americans and the United States 
Population 

Drinking norms and drinking practices in the United States and 
Asian countries have changed over time. For instance, Klatsky, 



397 



et al. (1983) reported decreases in the percentages of abstainers 
and heavy drinkers (three drinks per day on average) among 
White, Black, and Oriental HMO enrollees in Northern California 
of both genders. Among Oriental men, the percentage of abstain- 
ers decreased from 36.8%, between 1964 and 1968, to 19.9%, 
between 1978 and 1980, while the percentage of White men 
abstaining decreased from 15.5% to 8.6%. Among Oriental 
women, the percentage of abstainers decreased from 58.0% to 
39.7% during the same period; among White women it decreased 
from 25.0% to 12.2%. National drinking surveys also indicated 
changes in alcohol consumption patterns over the years (Hilton, 
1988a: Hilton, 1988b). 

In Japan, per capita alcohol consumption increased fourfold 
in the last four decades, and an increase in cirrhosis and esopha- 
geal cancer mortality rates among Japanese men followed (Par- 
rish, et al., 1993). In Taiwan, per capita alcohol consumption 
increased from 9 liters in 1957 to 27 liters in 1984 (Yamamoto, 
et al. 1988). Due to changes in alcohol consumption patterns in 
many countries, cross-sectional drinking surveys should not be 
used to characterize ethnic groups' drinking practices. There is 
a need to monitor changes in drinking practices among newly 
arriving immigrants as well as those who are settled in the 
United States. 

The Joint United States-Japan Alcohol Epidemiologic Project 
is the first survey to compare detailed drinking patterns among 
Japanese in Japan, Japanese Americans in Hawaii and Santa 
Clara, California, and Caucasians in Santa Clara (NIAAA and 
JNIA, 1991) (see table 1 for a detailed study design). Kitano and 
associates examined drinking practices among three study sites 
and Japanese Americans in Los Angeles from the previous study 
(Kitano, et al., 1988). They hypothesized that because Japanese 
immigrants in Hawaii were geographically clustered and physi- 
cally closer to Japan than those in Santa Clara, the Japanese 
Americans in Hawaii would be less assimilated to the local cul- 
ture than their Santa Clara counterparts, and their drinking habits 
would be more like those of the Japanese. In contrast, drinking 
patterns for Japanese Americans in Santa Clara would be similar 
to those among Caucasians. Their hypothesis was not supported. 



398 



They found that Japanese American men in Los Angeles had 
the highest percentage of heavy drinkers (35.8%), followed by 
Japanese men in Japan (32.4%), Japanese American men in 
Hawaii (29.0%), Caucasian men in Santa Clara (26.4%), and Japa- 
nese American men in Santa Clara (12.9%). Alcohol consumption 
for women was much lower than for men. Approximately 70% 
of Japanese women in Japan, Japanese American women in 
Hawaii or Santa Clara were either abstainers or infrequent drink- 
ers. Only 40% of Japanese American women in Los Angeles or 
Caucasian women in Santa Clara abstained or drank infrequently 
(Kitano, et al., 1988). 

Several factors made it difficult to study the effects of accul- 
turation on drinking practices among Japanese Americans. First, 
California is a favorite destination for immigrants as well as for 
U.S. residents from other states. Comparing drinking patterns 
for Asian Americans with those for Caucasians in California may 
not elucidate the degree of acculturation among Asian Ameri- 
cans, because Caucasian samples may have moved to California 
in recent years. 

Second, demographic factors, such as socioeconomic status, 
religious affiliations, and marital status differed considerably 
among Japanese Americans and Caucasians. This difference may 
account for the varying levels of alcohol consumption. Kitano, 
et al. (1988) found that over 60% of Japanese American men 
in Santa Clara reported an annual income of $40,000 or more, 
compared with 45.2% for Caucasian men in Santa Clara and 
19.8% for Japanese American men in Los Angeles. 

Third, descendants of Japanese immigrants who came to the 
United States in the beginning of this century as farmers tend 
to have higher educational achievement and higher-paid jobs 
than their parents and their grandparents. Examining the differ- 
ences in drinking practices across generations for the effects 
of acculturation may not be relevant due to the socioeconomic 
differences across generations. 

Fourth, changes in drinking practices in Japan and in the 
United States make it difficult to interpret the observed differ- 
ences in drinking patterns as a result of acculturation. 

Fifth, the difference in the sampling frame may account for 
the discrepancy among study sites; the Los Angeles sample 



399 



included a much higher percentage of Issei (the first generation 
of Japanese Americans), including Japanese business men, who 
tended to be heavy drinkers. The authors did not clarify whether 
the removal of these Japanese men from the analysis would 
result in much lower alcohol consumption levels for the Los 
Angeles sample. 

Although a study of Issei would give us an insight into the 
effects of acculturation on drinking practices, the number of Issei 
in the previous studies was too small to control for various 
factors affecting acculturation. Factors such as age at immigra- 
tion, educational attainment, occupation, length of stay in the 
United States, and English proficiency would be important to 
consider in future research. 

Differences in Drinking Practices 
among Asian Americans 

In this section, a brief description of the differences in drinking 
practices among Asian Americans is presented, followed by a 
comparison of specific Asian American populations' drinking 
practices with practices in their native countries, where data 
were available. 

In a northern California study during 1978 and 1980, Japanese 
American men had the lowest percentage of abstainers, followed 
by Filipino American men and Chinese American men (Klatsky, 
et al., 1983). In contrast, Filipino American women had the high- 
est percentage of abstainers, followed by Chinese American 
women and Japanese American women. In the Los Angeles study 
mentioned earlier, drinking levels of Filipino American men were 
comparable to those for Japanese American men, while drinking 
levels for Filipino women were much lower than those for Japa- 
nese women (Lubben, et al., 1988; Chi, et al, 1989). 

Chinese Americans 

Chinese Americans came to the United States from different 
parts of Asia. In the northern California study, among those born 
outside mainland United States, the largest percentage of Chinese 
Americans was from mainland China (59.9%) (Klatsky and Arm- 



400 



strong, 1991). This was followed by those born in Hong Kong 
(17.2%) and in Taiwan (7.0%). Except in Taiwan, differences in 
drinking patterns in various regions of China are not well known. 
Drinking surveys of Chinese Americans show that the drink- 
ing levels for both men and women were much lower than those 
for U.S. Whites and the other Asian groups (Kitano and Chi, 
1986-87; Klatsky, et al, 1983; Klatsky and Armstrong, 1991). 
The Los Angeles survey also indicated that Chinese Americans 
reported a higher prevalence of abstention and a lower preva- 
lence of heavy drinking though many liquor stores are owned 
by Chinese Americans (Chi, et al., 1989). Low cirrhosis mortality 
rates for Chinese Americans seem to support self-reported low 
alcohol consumption; the cirrhosis mortality rate for Chinese 
American men was 1.2/100,000 compared with 7.7/100,000 for 
U.S. White men between 1978 and 1980 (Yu and Liu, 1986-87). 
However, the sharp increases in alcohol consumption and alco- 
holism in Taiwan in the last 30 years (Yamamoto, et al., 1988) 
shows that drinking attitudes and alcohol consumption patterns 
have changed substantially. Even in a culture where the century- 
old Confucian idea of moderation in drinking has been a norm, 
the society is not free from a sharp increase in alcoholism. 

Japanese Americans 

Drinking attitudes, measured by how many drinks were appro- 
priate for certain drinking situations such as "as a parent, spend- 
ing time with small children, when with friends at home/' 
among Japanese in Japan and Japanese Americans in Hawaii 
and Santa Clara were examined, and drinking attitudes among 
three groups differed significantly (Tsunoda, et al., 1992). Japa- 
nese generally reported much more permissive attitudes than 
their Japanese American counterparts even after drinking levels 
were controlled for (Parrish, et al, 1990). Even though drinking 
levels for Japanese women were lower than those for Japanese 
Americans, Japanese women showed equally permissive atti- 
tudes toward drinking (Parrish, et al., 1990). Kitano, et al., (1992) 
reported similar findings about drinking norms for gender- and 
age-specific groups, such as a young man about 21 years old; 
Japanese respondents reported more tolerant drinking norms for 



401 



men than Japanese Americans, independent of gender. Attitudes 
about drinking and drunkenness among the three sites also dif- 
fered substantially, with the Japanese showing far more tolerant 
attitudes than the Japanese Americans sampled (NIAAA and 
JNIA, 1991). For example, 70% of Japanese men responded "yes" 
to "It does some people good to get drunk once in a while," 
compared with 30% of Japanese American men in Hawaii and 
24% in Santa Clara. Japanese women, who reported the lowest 
level of alcohol consumption, showed equally permissive atti- 
tudes about heavy drinking, as did Japanese men. Since Cauca- 
sian samples were not asked these questions, it is not clear how 
Japanese Americans differ from U.S. Whites in Santa Clara. Con- 
sidering the fact that the Japanese Americans' demographic pro- 
file include a high percentage of people born in the United States 
with high educational attainment, Japanese Americans' drinking 
norms may reflect mainstream U.S. drinking norms. 

Korean Americans 

Koreans have a reputation for heavy drinking (Yamamoto, et 
al., 1988). Koreans between the ages of 18 and 65 years in Korea 
were surveyed for a lifetime prevalence of alcohol abuse and 
dependence (3,134 respondents in Seoul, 1,966 respondents in 
rural areas; 51% of the sample were women) (Yamamoto, et al., 
1988). The lifetime prevalence of alcohol abuse was higher among 
respondents in Seoul than in rural areas, whereas the prevalence 
of alcohol dependence was higher among respondents in rural 
areas than in Seoul. This suggests differences in drinking prac- 
tices between Seoul and rural areas. The prevalence of alcohol 
abuse and alcohol dependence increased with age, and the preva- 
lence for female respondents was less than 10% of the prevalence 
for male respondents. The difference in the prevalence between 
genders reflects the Korean drinking norm, openly discouraging 
women from drinking. Gender prevalence differences were 
greater in rural areas than in Seoul. When these data were com- 
pared with data from a United States sample from St. Louis 
and New Haven, the Koreans had a much higher prevalence of 
alcohol abuse and dependency than the United States sample 
using DMS III criteria (source not listed by Yamamoto, et al.). 



402 



The prevalence was 21.8% in Seoul, 22.4% in rural areas in Korea, 
15.7% in St. Louis, and 11.5% in New Haven. 

Kitano and Chi, (1986-87) show that Korean Americans have 
the highest percentage of abstainers among Asian American 
groups for both men and women in Los Angeles (Kitano and 
Chi, 1986-87). Yamamoto, et al. (1988) attribute this phenomenon 
to the selective immigration of Koreans to the United States. 
Koreans who immigrate to the United States have higher educa- 
tional attainment and are more likely to be Christians (mostly 
Protestant) than Koreans in Korea. Over 50% of Korean American 
immigrants have Christian church affiliation compared with 12% 
for Koreans in Korea. Christian churches are a very important 
source of social support, and the churches discourage the use of 
alcohol. It is possible that underreporting of alcohol consumption 
among churchgoers in the survey may also account for low levels 
of self -reported alcohol consumption (Yamamoto, et al., 1988). 

In the Los Angeles study, Korean American men who chose 
to drink were more likely to be heavy drinkers than the other 
Asian American men. Among respondents who reported drink- 
ing, 46.5% of Korean American men were heavy drinkers, com- 
pared with 34.7% of Japanese American men and 18.1% of Chi- 
nese American men (Chi, et al., 1988). This suggests the heteroge- 
neity of Korean Americans, and the overall high percentage of 
abstainers does not indicate an absence of alcohol problems 
within this group. 

Filipino Americans 

Drinking practices of Filipinos in the Philippines are not well 
known. However, the Philippines are considered to have a strong 
Western influence on their culture due to a long history of coloni- 
zation by Spain and the United States (Lubben, et al., 1988). 
Drinking patterns for Filipino men were closer in style to the 
West, i.e., heavier alcohol consumption, than to Asian Americans 
(Kitano and Chi, 1986-1987). In contrast, Filipino American 
women had a high percentage of abstainers, and their drinking 
patterns were similar to those for other Asian American women. 
However, respondents in this survey were not representative of 
Filipino Americans in the United States. Only 3% of the sample 



403 



was born in the United States, and over 90% had some college 
education; two-thirds were Catholic, and the majority reported 
attending weekly religious services (Lubben, et al., 1988). 

Filipino Americans who were born in Hawaii were less likely 
to be abstainers than those who were born in the Philippines; 
the percentage of abstainers for Filipino Americans who were 
born in Hawaii was 15.1% compared with 39.6% for Filipino 
Americans born in the Philippines (Johnson, et al., 1987). Accul- 
turation seems to play an important role in drinking practices. 
Much less is known about drinking practices for Filipino Ameri- 
cans than for those Japanese Americans or Chinese Americans 
in Hawaii and in the mainland United States. Further research 
is necessary to figure out drinking practices in different regions. 

Indochinese Refugees 

The incidence of substance abuse is increasing at alarming rates 
among Indochinese refugees (Yee and Thu, 1987). A study of 
840 Indochinese refugees (90% Vietnamese) in Houston, Texas, 
and several cities in Louisiana showed that 40% of the respon- 
dents reported that they used some alcohol to diminish or handle 
sorrows or problems, and 5.8% used a lot of alcohol to do the 
same. The greater the refugees 7 worries, concerns, troubles, and 
depression, the higher the usage of alcohol and other drugs. 
Living in a more traditional, extended family household struc- 
ture was associated with lesser use of alcohol and other drugs. 
Those with higher education had better English language abilities 
and were less likely to report depression (Yee and Thu, 1987). 
Their alcohol consumption patterns were not presented in the 
paper. 

Discussion on Prevention Research 

These data, although limited in scope, suggest that drinking 
practices among Asian Americans differ substantially. In studies 
to date, Japanese American men generally had the highest level of 
alcohol consumption, and Chinese Americans the lowest. Asian 
American women have tended to have much lower alcohol con- 
sumption than their male counterparts. Japanese American 



404 



women generally had the lowest abstention rates. The observed 
differences in alcohol consumption may in part reflect differences 
in the proportion of individuals born in the United States, as 
well as differences in socioeconomic status. The percentage of 
Japanese Americans born in the United States was generally over 
70%; other Asian American groups had much lower percentages 
born in the United States, with the percentages varying greatly 
among studies. In the Los Angeles study, the percentage of the 
respondents born in the United States was 11.0% for Chinese 
men and 13.8% for Chinese women (Chi, et al., 1989). 

In a study of the Health Maintenance Organization (HMO) 
enrollees in northern California, 39.9% of Chinese men and 41.8% 
of Chinese women were born in the United States (Klatsky and 
Armstrong, 1991). These HMO enrollees were more likely to be 
college graduates than were the Los Angeles samples. Asian 
Americans born in the United States were less likely to be abstain- 
ers than those born outside the United States (Klatsky, et al., 
1983). A study in Hawaii also showed similar trends; Asian 
Americans (Chinese, Filipino, and Japanese) born in Hawaii had 
substantially lower rates of abstention than those born outside 
Hawaii (Johnson, et al., 1987). These studies suggest that place 
of birth is a better predictor of abstention rates than ethnicity. 

Future research should examine the association between per- 
ception of alcohol abuse and self-reported drinking practices and 
drinking problems across populations. These differences may 
inflate or deflate self -reported alcohol consumption and drinking 
problems. Geographic differences in drinking practices within 
ethnic groups also need to be explored because drinking practices 
differ among regions (dry vs. wet regions). Previous studies were 
based on the West Coast because many Asian Americans reside 
there. However, drinking practices for Asian Indians, a large 
Asian American group, have never been studied. 

Asia has a long and rich history of folk medicine and treat- 
ment, and each ethnic group has its own belief about illness and 
treatment. Hmong believe that a person's life is predetermined 
and medical care is worthless (Uba, 1992). These refugees, with 
little exposure to Western culture, are the most challenging for 
prevention research because little is known of their cultural 



405 



beliefs about alcohol abuse and alcoholism. Yet, they may be the 
highest risk group for alcohol abuse, as indicated by the study 
of refugees in Texas and Louisiana (Yee and Thu, 1987). 

Research on these linguistically and culturally diverse popu- 
lations requires good rapport between researchers and local com- 
munities. Bilingual researchers who are familiar with ethnic cul- 
ture are invaluable for conducting research among Asian Ameri- 
cans and Pacific Islanders. These researchers can give feedback 
to the community about the study results and work with them 
on prevention. 

There is a need to standardize the measurement of alcohol 
intake and to categorize drinking levels across studies for com- 
parison. In the Los Angeles study (Kitano, et al., 1988), modified 
quantity and frequency were used. With this method, the per- 
il centage of heavy drinkers for Japanese American men in Oahu, 
Hawaii, was 29.0%, compared with the corresponding rate of 13% 
(heavier drinkers, > = 30 ml of ethanol/day) using the drinking 
categories adopted by the National Institute on Alcohol Abuse 
and Alcoholism. It is desirable to develop a drinking categoriza- 
tion that reflects the risk of alcohol-related morbidity and mortal- 
ity. For example, an average of three drinks or more per day 
was associated with an increased risk of deaths due to cirrhosis 
of the liver (Parrish, et al., 1993). 

Conclusion 

This paper reviewed the history of immigration, demographic 
profile, and drinking practices among Asian Americans. 
Research about Asian American and Pacific Islander populations 
is limited, and the use of extant data is necessary to monitor the 
prevalence of alcohol abuse and alcoholism. Listed below are 
some areas in which more study and data are needed: 

• immigration patterns, 

• ethnic-specific cirrhosis mortality over time for larger eth- 
nic groups, such as Chinese, Vietnamese, Koreans, and 
Indians, 

• alcohol consumption, alcohol-related morbidity and mor- 
tality using HMO enrollee databases in areas of high con- 
centrations of Asian Americans and Pacific Islanders, and 



406 



• surveys of Asian American and Pacific Islander clients at 
the bilingual counseling services to examine the magnitude 
of alcohol related problems. 

The image of Asian Americans, once considered a model 
minority, is changing as Asian gang violence and illegal Chinese 
immigrants have become the front page news. As the percentage 
of U.S.-born Asian Americans increases, alcohol consumption 
and alcohol-related problems for these groups would be expected 
to increase. Furthermore, the number of Asian Americans has 
been growing rapidly, and they may become a target for liquor 
industry marketing just as African Americans have been tar- 
geted. The continuous monitoring of drinking practices is crucial 
for preventing further increases in alcohol abuse. 

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19(l):77-83, 1987. 

Yu, E.H., and Liu, W.T. Alcohol use and abuse among Chinese- Americans. 
Alcohol Health and Research World, Winter:14-17 and 61, 1986-87. 

Welte, J.H., and Barns, G.M. Alcohol use among adolescent minority groups. 
Journal of Studies on Alcohol, 48:329-336, 1987. 

Xenos, P.S., Gardener, R.W., Barringer, H.R., and Levin, M.J. Asian Americans: 
Growth and change in the 1970s. In: Fawcett, J.T., and Carino, B.V., eds. 
Pacific Bridges: The New Immigration from Asia and the Pacific Islands, New 
York: Centers for Migration Studies, 1987, pp. 249-284. 



409 



s 

R 



19 

Asian and Pacific Island 

Community Alcohol 

Prevention Research 

Ford H. Kuramoto 



Introduction 

For many years, the general public perceived Asian and Pacific 
Islanders as the minority group that has been successfully accul- 
turated. Recently, however, even the popular literature indicates 
differing perspectives on this minority group. The lead article in 
Time magazine (Aug., 31, 1987) entitled, ' 'Those Asian- American 
Whiz Kids," describes several Asian and Pacific Islanders who 
were very successful in school and related activities. The article 
drew the following conclusion: "The largely successful Asian- 
American experience is a challenging counterpoint to the charges 
that U.S. schools are now producing less educated mainstream 
students and failing to help underclass Blacks and Hispanics." 
Four months later, the Los Angeles Times published an article 
entitled, "Lost in L.A.," about a Vietnamese teenager who was 
involved in a Chinatown robbery attempt. Sang Nam Chinh, a 
19-year-old refugee from Vietnam, was the lookout for a failed 
jewelry store robbery, resulting in one Los Angeles Police Depart- 
ment officer killed and another wounded. Chinh was also 
wounded and later went to prison. These two articles describe 
very different perspectives on the Asian and Pacific Islander 
communities. In reality, the Asian and Pacific Islander popula- 



411 



tions are both ' 'successful' ' and "lost." It is crucial that alcohol 
researchers understand and appreciate this disparity. 

The objectives of the paper include: (1) briefly review the 
available literature on the drinking patterns of Asian and Pacific 
Islanders, (2) explore a few important conceptual, methodologi- 
cal, and cultural issues related to community-based research in 
Asian and Pacific Islander communities, (3) describe some efforts 
at collaboration between Asian and Pacific Islander communities 
and alcohol prevention researchers, and (4) discuss specific 
examples of alcohol prevention challenges in the Asian and 
Pacific Islander communities. 

Review of Literature on Drinking 
Patterns of Asian and Pacific 
Islanders 

Few publications discuss the use of alcohol among Asian and 
Pacific Islanders. However, the National Institute on Alcoholism 
and Alcohol Abuse (NIAAA) funded research projects on alcohol 
use among Asian and Pacific Islanders and published the results. 
One monograph, "Alcohol Use Among U.S. Ethnic Minorities" 
(NIAAA, 1989), includes several articles dealing with alcohol 
use in Hawaii; alcohol use among Chinese, Japanese, Koreans, 
and Filipinos; and the "flushing" response to alcohol use. How- 
ever, very little incidence and prevalence data were presented. 
This is due to the lack of local, state, or national data collected 
on Asian and Pacific Islanders living on the U.S. mainland. In 
general, data on drinking patterns among Pacific Islanders is 
even more difficult to obtain. 

Although little data are available, the Republic of Palau Con- 
ference on Alcohol and Other Drugs in August 1991 identified 
the problem of alcohol consumption, especially among teenagers, 
as a serious problem (Polloi, Anthony. Personal Communication, 
August 1991). Hanipale and Whitney (In process) reported that 
alcohol consumption in American Samoa was about 22 gallons 
(of unspecified alcoholic beverage) per capita and on the increase. 

Zane and Sasao found in reviewing the research literature 
that Asian and Pacific Islanders in general reported to have used 



412 



alcohol and other drugs (cigarettes and marijuana) at lower rates 
than African Americans, Hispanics, and Whites (Zane, et al., in 
process). They also identified a study indicating that alcohol 
drinking patterns among young Asian and Pacific Islander males 
were similar to those found for a national sample of young adult 
males (Cahalan and Cisin, 1976). Further, Cahalan and Cisin 
found that certain Asian and Pacific Islander groups had a high 
proportion of heavy drinkers. The heaviest drinkers were the 
Japanese subjects (25.4%), and Filipino subjects (19.6%), followed 
by the Koreans (14.6%) and Chinese (10.4%). 

A Canadian study (Legge and Sherlock, 1991) found that 
highway traffic violations for driving while intoxicated were 
very low for Canadian Chinese (3 in 50,000 cases). However, a 
focus group of Sikh (Indo-Pakistani), who would be considered 
Asian and Pacific Islanders if they were in the U.S., estimated 
that 25% of males have alcohol problems. 

Kim provides a useful literature review of various cultural 
constructs and discusses their relevance to Asian and Pacific 
Islanders (Kim, 1992). Kim examined several concepts regarding 
culture. He attempted to show how Asian and Pacific Islander 
alcohol use may be related to cultural issues. He also discussed 
culturally competent services and their importance in breaking 
the cultural barriers to seeking help. 

Sue, et al. (1979) found that permissive attitudes associated 
with greater acculturation were related to heavier alcohol con- 
sumption. These important findings indicated that in alcohol 
consumption, Asian and Pacific Islanders use had been underesti- 
mated. Chi indicated that differences among Asian and Pacific 
Islanders in their alcohol consumption can be attributed to cul- 
tural patterns brought to the U.S. by their ancestors (Chi, et al., 
1988, 1989). 

Conceptual Methodological, and 
Cultural Issues 

Conceptual Issues 

In discussing conceptual issues in conducting community 
research, it is important to consider how the term // community ,, 



413 



is defined. Although Asian and Pacific Islanders tend to be con- 
centrated in urban areas, there are substantial, and growing, 
enclaves of Asian and Pacific Islanders living in rural communi- 
ties on the U.S. Mainland, Hawaii, and the Pacific Islands. 

Communities are often thought of as a geographical area 
with specific populations. Most of the Asian and Pacific Island 
population does not necessarily live in "Chinatown/ 7 "Little 
Tokyo," "Koreatown," "Little Saigon," or "Manilatown." 
Rather, the populations tend to be scattered across urban and 
rural areas. Care must be taken to accurately identify the Asian 
and Pacific Island population that is being defined as the "com- 
munity." For example, there may be an Asian and Pacific Island 
group identified as a Chinese population. This Chinese popula- 
tion, however, could be Chinese from the People's Republic of 
China, Taiwan, Hong Kong, or "ethnic Chinese" from Vietnam, 
Mexico, Canada, or many other parts of the world. It is also 
not uncommon for Chinese enclaves (e.g., "Chinatowns") to be 
composed of individuals who speak various Chinese dialects, 
as well as ethnic Chinese, who may speak Vietnamese or other 
languages. 

Methodological Issues 

Two major methodological issues of concern to research on alco- 
hol research among Asian and Pacific Islanders include language 
abilities and literacy and ethnic bias. 

Language Abilities and Literacy: Researchers should be aware 
that the Western concepts of scientific method and research are 
not necessarily understood by everyone, especially new immi- 
grant populations with little formal education. Many Asian and 
Pacific Island populations do not have much formal education, 
and may not be literate in their own language, much less English. 
Written communication will be difficult with some Asian and 
Pacific Island groups. Oral interviews and ethnographic 
approaches may be preferable sometimes. 

Ethnic Bias: Westermeyer's Ethnic Bias (1989) makes the point 
that the U.S. Census Bureau data has ethnic and racial biases. 
For example, many ethnic minorities are not counted. Reasons 
for this undercount include the reluctance of many of these 



414 



groups to reveal themselves to government authorities for fear of 
legal difficulties and other adverse consequences. This reluctance 
applies to many Asian and Pacific Island groups, especially those 
that are recently naturalized citizens, refugees, or immigrants. 
In addition, many Southeast Asians moved from one location 
to another, trying to rejoin relatives scattered across the 
United States. 

Another ethnic bias results from the sampling procedures 
used. For example, institutional records, such as hospitals and 
other public facilities, which are used as a data source, often do 
not accurately identify Asian and Pacific Islanders, particularly 
regarding their specific subgroup identification. 

Ethnic and racial bias may also exist in data analysis and 
interpretation. Many surveillance data, national surveys, and 
other epidemiological studies normally do not include specific 
Asian and Pacific Islander subgroups. Putting all Asian and 
Pacific Islanders into the general category of "Asian" or "other" 
makes the data difficult to analyze and interpret. In addition, 
interpreting data requires a certain level of "cultural compe- 
tence" and a thorough understanding of cause and effect relation- 
ships in diverse cultural groups. Because of the small number 
of the studies on Asian and Pacific Islander alcohol and other 
drug use and abuse, researchers must carefully interpret their 
findings, especially when generalizing findings to subgroups 
within the Asian and Pacific Islander populations. 

According to Zane and Sasao (In process), the apparent low 
levels of alcoholism among Asian and Pacific Islanders were 
usually attributed to physiological reactions to alcohol and symp- 
toms of discomfort. Some studies regarding the higher sensitivity 
of Asian and Pacific Islanders to alcohol have shown that cultural 
and environmental factors need to be examined along with the 
biomedical factors. Further, none of these research findings are 
based on a comprehensive study of all of the major Asian and 
Pacific Islander subgroups. Finally, the cultural appropriateness 
of the research instruments may not have been sufficiently con- 
sidered, and an assumption may have been made that pharmaco- 
logical research is "context-free." 

Research on alcohol and other drug issues regarding Asian 
and Pacific Island populations typically uses limited sample pop- 



415 



s 



ulations of university students or individuals in AOD treatment 
programs (Zane and Sasao, In process). The existing research 
does not generally include sample broad segments of the Asian 
and Pacific Island populations in a random sample. Two excep- 
tions are the California statewide alcohol needs assessments by 
Special Services for Groups (1991), and the California statewide 
drug abuse needs assessments by Sasao (1991). These studies 
are discussed below. 

Cultural Issues 

Cultural issues are important factors in conducting Asian and 
Pacific Island research. Research needs to be conducted in a 
culturally competent manner that will be "good science" and 
will ultimately help empower the Asian and Pacific Island popu- 
lations. 

The Special Services for Groups study revealed that cultural 
issues affect drinking patterns in the various Asian and Pacific 
Island communities. One part of this study described how six 
different Asian and Pacific Islander groups were categorized 
based on their responses to the question, "Why do you drink?" 
The categories were "Social/peer Influence," "Escapist" (an 
attempt to rid themselves of unpleasant feelings, e.g., depres- 
sion), and "Self- Actualizing." This study showed that subgroups 
drink for differing reasons. For example, Southeast Asians gave 
Social /Peer Influence as their reason for drinking more often 
than any other subgroup. In contrast, Filipinos identified with 
this category least. Filipinos and Koreans chose the Escapist 
category most often. In contrast, the Japanese chose the Self- 
Actualizing category most often. The Chinese subjects chose this 
response least often. 

An epidemiological survey of alcohol use among Chinese, 
Japanese, Whites, and Asian- Whites of mixed parentage in 
Hawaii showed that both biological and cultural issues impact 
drinking patterns (Wilson, et al., 1978). Whites tended to drink 
more and flush (reddening of the face and other physical reac- 
tions to alcohol) less than Chinese or Japanese. The Chinese and 
Japanese did not differ from each other in drinking levels or 
flushing patterns. People of Asian-White mixed ancestry had a 



416 



mean alcohol consumption level close to the White subjects, but 
Asian- Whites had a greater tendency to flush than did the White 
subjects. These results showed that biological and cultural vari- 
ables such as marital assimilation influence alcohol consumption 
(Zane and Sasao, In process). 

Asian and Pacific Islanders have commonalities and differ- 
ences in the way they perceive alcohol consumption versus other 
drugs. In a study of Vietnamese in Houston, Texas, and Louisi- 
ana, approximately 45% of the sample of 840 refugees reported 
problems with alcohol and /or tobacco use (Yee, et al., 1987). 
However, other drug use was not suggested as a problem. These 
Vietnamese refugees said that alcohol and smoking were an 
acceptable way of dealing with stress and other personal prob- 
lems. 

The Hanipale and Whitney study of drinking patterns among 
American Samoans describes the impact of the Samoan culture 
on their drinking patterns (Hanipale and Whitney, In process). 
The authors say that consuming alcohol was primarily a male 
activity in a society where females consumed alcohol only on 
special occasions. Young men in American Samoa drank in a 
social group. This was typically done away from the village, in 
a remote area where they did not disturb others. They gathered 
in small groups and their alcohol consumption tended to go 
through an informal ritual, beginning with a phase of informal 
banter and getting acquainted. These young men, typically 
between the ages of 14 and 25, then continued drinking into the 
next phase of the social interaction, labeled "daring entertain- 
ment/' where the banter included more joking and teasing 
among themselves. This phase also included singing, with indi- 
viduals providing entertainment, and tended to be noisier and 
more boisterous than the initial phase. This tone is in contrast 
to the strict, quiet demeanor that men of their age had to show 
in their villages where the elders and chiefs have higher status 
and the young men must work hard, do their duty, and wait until 
they are senior enough in the village to have more prerogatives. 

As the alcohol consumption continued, typically without any 
food, the social interaction took on a "philosophical intimacy/ , 
where group members began to talk about more serious matters, 



417 



e.g., how they personally felt about their lives, problems in their 
family, and romantic relationships. When this "intimate" atmo- 
sphere in the group remained, the group would end with every- 
one going home on good terms. However, when some members 
of the group became angry, the interaction deteriorated into the 
final phase, which was the "breakup" of the group. This normally 
occurred when two or more individuals had an exchange of 
angry words and the group ended with bad feelings and /or 
physical fights, sometimes resulting in physical injury. 

Older men drank in their own homes, served by their wives. 
They were waited on by the women of the family, provided food, 
and whatever they wanted while they were drinking. However, 
these men sometimes beat their spouses and children while 
drinking. It is estimated that as many as 30% of Samoan men 
n have a drinking problem. 

The drinking patterns in American Samoa are different from 
the United States. There are also differences in treatment 
approaches. For example, there is a Samoan equivalent to 12- 
Step groups. However, these self-help groups are not very similar 
to "AA" groups in the United States mainland. While they are 
self-help groups, there is virtually no confidentiality, since in 
American Samoa, everyone knows each other. The older men in 
these groups have higher status and typically do not self-disclose 
any personal failings, e.g., guilt. Younger men never confront 
their elders in the group. These groups tend to be focused on 
group activities and the welfare of the group, versus dwelling 
on personal feelings, problems, and self-disclosure. 

Samoans interpret personal responsibility for their drinking 
behavior differently from other cultural groups. When a Samoan 
man gets drunk, it is considered a temporary example of bad 
judgement and a mistake. It is not considered a long-term, life- 
long personal problem, as it is generally considered by the usual 
United States mainland interpretation. When a Samoan man gets 
drunk and causes a problem, he will perform a ritualized apology 
to all of those whom he has offended. Under normal circum- 
stances, the offending man will be forgiven and the slate will 
be wiped clean. If a particular individual continues to create 
problems, then he will be brought before the chiefs and the elders 



418 



of the village. The man and his family will be told what they 
must do to solve the problem. This process is obviously much 
different from the patterns of alcohol abuse and recovery in 
mainstream America. 

Finally, Samoan men, according to Hanipale and Whitney, 
drink because they want "to feel strong," and to overcome their 
sense of powerlessness. Samoan society has undergone dramatic 
changes because of westernization, where the traditional roles 
and status of the chiefs have been eroded by Western culture, 
"cash economy," and the American-style educational systems. 
These changes detract from traditional culture and family prac- 
tices. 

The Hanipale and Whitney study points out the need to 
consider cultural factors in research, including developing cul- 
turally appropriate instruments and design. Each of the Asian 
and Pacific Island groups have different drinking patterns and 
reasons for drinking. Thus, prevention and treatment programs 
must identify these factors accurately in designing culturally 
competent services. 

Collaboration Between Asian and 
Pacific Island Communities and 
Alcohol Researchers 

There have been isolated instances in the past when Asian and 
Pacific Islander groups were not involved in planning and imple- 
menting research projects. As a result, this affected the availabil- 
ity of subjects and created a basic lack of cooperation from indi- 
viduals and organizations that could have provided assistance. 
This process also detracted from the research findings. As a 
result, the contribution of data to the Asian and Pacific Islander 
communities was diminished. 

The basic ethics involved in conducting good research are 
the same as with any community. This includes respecting the 
dignity of the subjects, the human subject's research protection, 
and the potential benefit to the population being researched. The 
ethical considerations and the emphasis on human dignity are 



419 



\ 



basic requirements for any research project. Development of a 
good research project will support subject empowerment. The 
idea of empowerment as described by Rappaport (1987) offers 
a helpful series of steps in developing community empowerment, 
resulting in getting the "buy-in" of those who should be actively 
participating and benefiting from the project. The key is to share 
decision-making power with community members. 

To have access to a research population, the researcher must 
engender trust, credibility, and confidence. Researchers are usu- 
ally from university settings, and some researchers have not been 
culturally sensitive, or have not adequately contributed back to 
the communities they used for subjects. Part of developing the 
necessary cooperation is to have a reasonable way of " giving 
back" to the community. Contributing something to the commu- 
nity can take many forms, for example, providing a personal 
\ briefing on the results of the research and offering technical 

assistance to community-based organizations. In addition, pro- 
viding stipends or compensation for the time that the subjects 
give to participate in the research project is often very helpful. 
This is particularly true where the subjects are low-income, and 
many Asian and Pacific Islanders are low-income. 

The California Statewide Alcohol Needs Assessment (Special 
Services for Groups, Inc., 1991) study demonstrates the efficacy 
of community involvement in a research project. The project was 
characterized by community participation in the design and the 
conduct of the research. The study emphasized the importance 
of studying as many Asian and Pacific Islander subgroups as 
possible throughout the state by involving individuals in a great 
many focus groups. Also, the tentative results of the study were 
shared with the community groups that had participated in the 
research, before the research findings were formally distributed. 
As a result, Asian and Pacific Islander groups felt that the study 
was relevant and helpful. 

An appropriate method of bridging cultural, socioeconomic, 
educational, and language differences must be found. One 
method of bridging some of these differences is to make an 
arrangement with an indigenous Asian and Pacific Island com- 
munity-based organization to assist in the sampling strategy. 



420 



Organizations such as the National Asian Pacific American Fami- 
lies Against Substance Abuse, Inc.; Asian Pacific Planning Coun- 
cil (Los Angeles), and the Pacific Island Substance Abuse Council 
(Guam) can assist in identifying community-based agencies that 
may be able to facilitate entree and create working relationships 
with Asian and Pacific Island communities. 

Asian and Pacific Island populations are anxious to have 
good AOD-related research performed. Most communities 
would be willing to cooperate with researchers if their concerns 
were addressed. Researchers must, therefore, treat Asian and 
Pacific Island populations with dignity and sensitivity while 
helping them in solving their alcohol problems. 

In "Problems in Pacific/Asian American Community 
Research/ 7 Yu (1982) outlined a number of problems she 
observed in doing research among Asian and Pacific Islanders. 
Research activities in ethnic communities sometimes became 
complicated by internal community politics. For example, a vari- 
ety of agendas were acted out within the community, by individ- 
uals, each representing themselves as the true spokesperson of 
the community. Questions often arose about who should do the 
research, the theoretical presuppositions, the demand for bias- 
free methods, the need for research to be relevant to policy, 
community accountability, and theoretical interpretations. Yu 
offered the following recommendations for improving the rela- 
tionship between the community and researchers: 

1. Social researchers should work closely with the communities 
they plan to study to make sure that community groups have 
their perspectives heard and included. 

2. Researchers should not be coerced into conducting research 
without the appropriate procedures and scientific rigor. 

3. Community leaders need to understand the role that Asian 
and Pacific Islander researchers must play, i.e., both the social 
scientists as well as members of the Asian and Pacific Islander 
communities. 

4. All parties should appreciate the roles that each community 
member plays and that there may be shared values in advocat- 
ing for Asian and Pacific Islander community needs, but the 



421 



methods by which individuals choose to express their values 
may be different. 

5. Community members should remember that research find- 
ings may not always be tangible and immediately applicable 
to solving existing human service problems. 

6. Ethnic researchers have an obligation to assist communities 
in improving human services within those communities. 

The above recommendations illustrate the need for clear com- 
munication between researchers, usually academicians, and 
community representatives. Often, differences in views on 
research can be resolved so that the research projects can be 
implemented. However, there may be a few situations where 
impasses occur and researchers have to respect the wishes of 
the potential research subjects and look elsewhere for volunteers. 
I; Understanding the role of research is very important, but, ulti- 

mately, empowering the community is the best way to assure a 
successful research project. 

Research priorities for Asian and Pacific Islanders have been 
identified in several different forums. These include the 1991 
California Statewide Alcohol and Drug Abuse Forum Report, 
the Proceedings of the Third NAP AF ASA National Conference, 
1991, and the policy paper by NAPAFASA to the Office of 
National Drug Control Policy (September 1991). 

Finally, some university researchers have difficulty establish- 
ing rapport with potential subjects. University researchers gener- 
ally have not been active and visible in community affairs where 
their support and participation are desired. Too often, academi- 
cians appear interested in community affairs only when they 
want assistance with their research projects. Technology transfer 
is not always a high priority for academicians, whereas it is a 
very high priority for community-based agencies. On the other 
hand, Chen, et al. (1992) have researched methods of public 
health education with Southeast Asians in the Midwest. Their 
research indicates that culturally competent techniques imple- 
mented by appropriate personnel with the necessary back- 
ground, training, and experience can achieve effective health 
education and research results. 



422 



One example of a joint community- and university-based 
study was the NIMH-funded Nisei History Project, which was 
performed by the University of California, Los Angeles, with 
the collaboration of the Japanese American Citizens 7 League (a 
national civil rights organization). This collaborative partnership 
made the research possible and allowed access to many subjects 
in the Japanese American population throughout the United 
States, as well as identifying experts regarding Japanese Ameri- 
can history and behavioral sciences. 

NIMH also funded a National Asian American Mental Health 
Research Center at UCLA. This is currently the only national 
research center (on any type of public health issue) for Asian 
and Pacific Islanders. As an ethnically focused research enter- 
prise with strong community ties, it has excellent access to Asian 
and Pacific Island communities, helps in empowering communi- 
ties, and promotes technology transfer. 

The NAPAFASA Programs of National Significance Project, 
funded by the Center for Substance Abuse Prevention, is an 
example of how community-based organizations can assist in a 
national demonstration project. This demonstration project was 
to identify, describe, and collect modest program evaluation data 
on existing substance abuse prevention programs focused on 
Asian and Pacific Island youth. The project identified eighteen 
community-based Asian and Pacific Island organizations on the 
U.S. mainland, Hawaii, and the Pacific Islands. Because it was 
a community-based organization itself, NAPAFASA had access 
to these organizations, which were more than willing to assist 
in the development of effective youth prevention strategies and 
model building. 

Research Challenges 

Individual Challenges 

On the individual level, Zane and Sasao (In process) concluded 
that alcohol use can best be explained by a combination of ' 'recip- 
rocating' ' forces, including physiological, cultural, and environ- 
mental forces. Cultural factors in alcohol use include social skills 



423 



deficits and knowledge of how social skills are acquired by Asian 
and Pacific Island immigrants. In addition, the impact of cogni- 
tive-behavioral and community education programs on primary 
prevention and early intervention, family cohesion, peer relation- 
ships, and environmental forces (e.g., poor housing, racism, and 
anti- Asian violence) are forces that affect alcohol use. Researchers 
must therefore consider cultural issues when doing research 
among Asian and Pacific Islanders. 

Public Policy Challenges 

There are research challenges at the community level as well. 
Studies are needed to assess the extent to which alcoholic bever- 
ages manufactured in Asia and Pacific Basin countries and sold 

S in the U.S. contribute to the drinking problems among Asian 

:•) and Pacific Islanders. Restaurants and retail stores with liquor 

licenses, operated by Asian and Pacific Islanders in the U.S., 

J affect drinking patterns and family attitudes regarding alcohol. 

Many restaurants and stores sell alcohol in the Chinatown, Little 
Tokyo, and Koreatown areas of Los Angeles. In certain areas of 
Los Angeles, attempts are being made to reduce the number of 

; retail liquor outlets operated by Asian and Pacific Island mer- 

chants (Nakano, 1993). The concentration of these retailers in 
South Central Los Angeles has increased tensions. However, 
constructive ways of easing tensions are being implemented. 
These efforts include helping Asian and Pacific Island merchants 
to convert to businesses that do not sell alcohol. Further research 
should be done on the impact of public policy regarding alcohol 
sales and consumption among Asian and Pacific Islanders. 

Prevention/Intervention Challenges 

Due to the lack of epidemiological and etiological data, ethno- 
graphic studies, cultural research, and evaluation studies, very 
limited knowledge of specific alcohol prevention /intervention 
issues is available. Nevertheless, the California alcohol needs 
assessment study (Special Services for Groups, 1991) shows that 
any prevention effort needs to include a study of the reasons 
specific subgroups choose to drink. Effective prevention strate- 



424 



gies can then be designed and implemented specifically for each 
subgroup. The design of these interventions must be very specific 
to each of the Asian and Pacific Islander subgroups. The interven- 
tions will also have to vary within the subgroups by gender, age 
group, levels of acculturation, and socio-economic class. 

Barriers to effective human service interventions for Asian 
and Pacific Islander groups include stigma, shame, denial, lack 
of financial resources, and an understanding of Western-style 
human service prevention and treatment methodologies. In addi- 
tion, getting two or more Asian and Pacific Islander subgroups 
to collaborate among themselves can be problematic. Many of 
these groups do not have a history of working together and 
understanding each other's problems. Very often, community 
leaders are concerned about political issues and their spheres of 
influence and are therefore not predisposed to collaborating with 
other leaders around human service problems. Furthermore, col- 
laboration with researchers, particularly those who are consid- 
ered outside the Asian and Pacific Islander communities, tend 
to get mixed reactions and, in some instances, very little response 
to collaborative overtures. Many populations that are not highly 
educated along Western lines will not understand Western style 
research concepts and methods, and therefore simply have diffi- 
culty relating to attempts at implementing the scientific method 
and the design of research projects. Researchers must develop 
culturally relevant techniques to overcome these barriers. 

A long-term educational process is needed to improve com- 
munications between Asian and Pacific Islander communities 
and researchers. This long-term process must affect both the 
research community and the Asian and Pacific Islander commu- 
nities. When the researchers are culturally competent Asian and 
Pacific Islanders, the educational process and communication 
among groups will tend to be easier. That is why more Asian 
and Pacific Islanders must be involved in doing research regard- 
ing their own communities. As stated earlier, "ownership" and 
' 'buy-in' ' to the research project make the whole process more 
effective. Trust is key in establishing a productive research rela- 
tionship with Asian and Pacific Islander communities (other 
groups, too). However, to engender this trust, there must be 




425 



meaningful communication, i.e., through language, customs, 
mores, values, norms, and attitudes. Simply talking to commu- 
nity groups and research subjects in the language in which they 
are most comfortable (e.g., Hmong, Korean, Palauan, Microne- 
sian, Marshallese, Samoan, Chamorro, and Vietnamese) is very 
important. 

Finally, researchers must also conduct research in an ethical 
manner to create an atmosphere that lends itself to honesty and 
trust between the researchers and the subjects. Human subjects, 
and Asian and Pacific Islander communities, must be provided 
informed consent, and their civil and personal rights as research 
subjects must be strictly protected. Obviously, no research sub- 
jects should be injured or exploited, as in the syphilis studies 
done many years ago on African American subjects. 

Conclusion 

Relatively little is known about the alcohol and related issues 
among Asian and Pacific Islanders. This is unfortunate, because 
what is available in the literature indicates that there are interest- 
ing facets to discover in this population. What has already been 
learned and what may be learned in the future will hopefully 
benefit all groups in the diverse American fabric. More research 
is needed to be sure. 

NIAAA can play a crucial role in advancing research among 
Asian and Pacific Islanders by holding conferences and provid- 
ing technical assistance for researchers regarding Asian and 
Pacific Islanders issues; expanding the announcements of 
research opportunities that include a special focus on Asian and 
Pacific Islanders; helping Asian and Pacific Islanders in develop- 
ing a comprehensive data collection system regarding alcohol 
issues, and developing a partnership between alcohol researchers 
and prevention and treatment service providers to assure tech- 
nology transfer. 

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Chi, I.; Lubben, J.E.; and Kitano, H.L. Differences in Drinking Behavior Among 
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NIAAA, Alcohol Use Among U.S, Ethnic Minorities. NIAAA Research Monograph 
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20 



Issues in Alcohol Abuse 

Prevention Research in Asian 

American Communities: A 

Researcher/Community 

Perspective 

Davis Y. Ja 



Introduction 

My comments are divided into two sections: (1) a few comments 
on the papers presented on Asian and Pacific Islanders and 
(2) more extensive comments on the entire working group, my 
thoughts on this process and the discussions that have taken 
place over the last two days. I approach this discussion from 
the background of someone who teaches psychology, conducts 
research, and yet is very involved in my community. For the 
last 25 years, I have worked in nonprofit community-based orga- 
nizations focusing on Asian American mental health, drug abuse, 
AIDS, housing and labor in Seattle, Boston, Oakland, and now 
San Francisco. 

Discussions of Papers on Asian- 
American Communities 

Some comments that Dr. Kuramoto made about Asian and Pacific 
Islanders not being counted or included in the public health 



429 



strategy, I find Asians most often listed under an "other" cate- 
gory. This is a significant issue and a dilemma for our communi- 
ties; if you don't get counted, then you don't count. Similarly, 
significant problems within our diverse ethnic communities are 
ignored since the "data" in terms of the federal bureaucracy 
reflects only "others" and does not differentiate specific prob- 
lems with the Chinese community or the Vietnamese or Filipino 
communities. When you examine much of the aggregate data 
available, whether it's the household survey or the high school 
seniors survey, "other" is always present and probably accounts 
for approximately 15 percent of our resources in total research 
dollars. But who and what is "other" and to what degree does 
that provide us with any information that is meaningful for our 
communities? Since "other" is that little grab bag that contains 
s Asians and Native Americans and whoever else you can throw 

in, it isn't readily interpretable; it becomes meaningless for us 
or anyone else. 

A second and crucial issue that Dr. Kuramoto suggested 
earlier is the fact that we have 32 different distinct groups, differ- 
ent languages, different values, different aspects, different 
beliefs, different traditions. You want to conduct research in a 
Vietnamese community? Well, the fact is the Vietnamese commu- 
nity could be ethnic Vietnamese or Vietnamese-Chinese. Viet- 
namese-Chinese are primarily the boat people. These two groups 
often don't get along, and may not speak to each other. Assuming 
you hire someone to work with you, whether it is in a service 
capacity or let's say in prevention, and they're Vietnamese-Chi- 
nese. Well, their message may not be heard by someone who is 
ethnic Vietnamese. It's a very complex issue. 

I do want to address a few comments to the issue of "flush- 
ing" that has been brought up. I wholeheartedly agree that flush- 
ing has less of a bearing than social-cultural factors in terms of 
alcohol use and abuse. I think we've wasted a lot of federal 
dollars trying to understand the genetic factors underlying alco- 
hol abuse, particularly with Asians, and trying to find the magic 
bullet that somehow indicates that it's a genetic predisposition 
that factors into alcohol use and abuse. 

We also need to understand that the extended family is very 
important in our community. We also need to try to find ways 



430 



to incorporate extended families into prevention efforts. Further- 
more, social skills development and alternative recreational 
activities are also important tools that we can use as prevention 
interventions. Perhaps a multiple-method, multi-level approach 
incorporating various aspects of family involvement, teaching 
social skills, and providing recreational activities may be a better 
approach. That is what we are trying to do in San Francisco. 

I agree that AA does not work well with the Asian commu- 
nity, whether in Hawai'i or on the continent. It's not something 
that we have been able to incorporate in much of our current 
efforts. 

Religion does have some bearing in the mainland as well, 
particularly with some groups like Koreans, where there is a 
large number of Korean Christian churches with extensive con- 
gregations. Often we work closely with Korean ministers to 
incorporate their concerns and input into our prevention activi- 
ties. 

I also feel that cultural sensitivity cannot be separated from 
issues related to race. Cultural sensitivity may provide some 
skills and abilities for those attempting intervention activities, 
but race per se is a critical factor that cannot be simply differenti- 
ated from cultural-sensitivity. I do feel strongly that, in general, 
clients are most comfortable interacting with persons of their 
ethnic background and that indigenous treatment modalities are 
preferred, particularly with those who are immigrants, refugees, 
or those that have strong cultural traditions. 

Discussion of Working Group 
Presentations and Comments 

Now I'd like to make some comments regarding the last several 
days' discussion, particularly since I'm the last speaker. There 
are advantages and disadvantages to being the last speaker. I've 
had the opportunity of hearing what everybody else has to say, 
but there is much that has already been stated that I wanted to 
indicate earlier, and many of you have stolen my thunder. 

First, I want to indicate that this working group has been 
an interesting process. In many ways, this working group is a 



431 



microcosm of our ethnic reality in society. We are all researchers 
to some degree, but we have people of color and we have people 
who are White. It is interesting because, as we were discussing 
various issues during the previous presentations, the discussions 
began to get heated. When the discussions became heated, I felt 
like things were beginning to be put on the table regarding the 
issue of color and that we were beginning to really address some 
very important issues. But the process that we have here in this 
working group is very time-oriented, very linear-oriented, and 
it's not colored people's time. I know that Phyllis and everyone 
else has put much effort into this, and I'm not saying it's your 
issue; I'm saying it's the institute's issue. 

It is just that when the discussion got hot, what I would have 

liked to have seen is for us to continue that dialogue and push 

n through that, because that is how we get things done in the 

community. If you want to do research in our communities, you 

have to deal with us with that perspective, and that was missing. 

That is partly what it takes to do research, particularly applied 
and community-based research, and I hope that NIAAA takes 
this seriously. I hope that this dialogue continues and goes 
beyond just scratching the surface, because we have to break 
through this. We do not want to walk away angrily. If you are 
angry, let us talk about it so that we can move beyond and come 
together in real terms rather than just dealing with superficial 
niceties. 

Like I said, we are people of colors, we are from these various 
communities. Many of us are still a part of those communities. 
We might not live there, but we certainly work there. Janet 
Mitchell works at Harlem Hospital every day, Susie Rodriquez 
is down at East L.A., Bob Robinson is still in Philadelphia trying 
to deal with R.J. Reynolds — we are there, and we are not just 
feeling the pulse, because we are part of the pulse. I think that 
is really important. 

It is not that easy. I could leave, and I have, but I have come 
back home because it is what I want to do. It is my roots; I am 
committed to that community, and that is really important. 

And it's also very frustrating to stand here again saying the 
same things I have said repeatedly. We were here in 1980 speak- 



432 



ing to ADAMHA, saying the same things I'm saying to NIAAA 
today — the very same things. It was a research agenda then: what 
should we do to do research in the ethnic /racial community, how 
should we do it? Three weeks ago, Larry Brown and I were here 
speaking to NIDA, to the prevention research branch, about this 
issue, and here we are doing the same thing for NIAAA. 

So where does all this go? The one thing I know is that the 
pessimistic side of me says that it's 1992 and it's an election year. 
There is a pattern— 1980, 1984, and 1992. And then the optimistic 
side of me says, well, the demography has changed; it is inevita- 
ble, they can't ignore us any longer. The Asian context is here, 
our numbers are higher. Then I keep thinking back — here's the 
pessimism again — look at the African Americans. Their numbers 
are so much higher, and what have they gotten? 

The other thing Dr. Howard mentioned, we were talking 
about rape and pillage, and I want to bring that analogy back 
again, because there hasn't been a whole lot of rape and pillage 
from NIAAA in the Asian community; I have to admit that. But 
that is because, as far as our village is concerned, we are a couple 
of tiny low-down little huts down there. We're not even worth 
raping or pillaging. 

But the fact is, our numbers are growing and we're beginning 
to see some alcohol-related problems with the Samoans, Hawai- 
ians, and Japanese. What does that mean? They are coming — 
rape and pillage time. Maybe I should just start calling folks and 
saying Japanese community or Hawaiian community, watch out. 
NIAAA is coming. Because how are you going to come into our 
communities to do research? There's a million ways in the naked 
city, folks, and I've seen many of them because I've been there, 
and here are a few typical examples. 

(1)1 used to be the executive director of one of the biggest Asian 
nonprofit agencies doing substance abuse work in the United 
States. Someone will call me and say we have got a great 
proposal and we want to work in the Asian community. 
When I ask what is the proposal about, they say let's sit 
down and talk about it. And, oh, incidentally, it has been 
funded. So they want my population, it's been funded, they 



433 



have an impossible research design, and I tell them to get 
lost. Well, they go next door, down to the Asian social service 
center, and they talk to them and try to convince them, and 
they keep bouncing around until they find someone who is 
sympathetic because they need some dollars. They buy them 
off with some spare change and they get into that community. 
That is one way. 

(2) Here is a second way. Do people know what a Buffalo soldier 
is? Some people have heard of Buffalo soldiers? Buffalo sol- 
diers were Black cavalrymen after the Civil War who went 
out and killed the Indians for the White men. Well, we have 
Buffalo soldiers in the Asian community, and some of them 
are Asian researchers. There are actually a substantial num- 
ber of them. When you look at the research institutes, there 

yj are a disproportionate number of Asians. But you know, it 

is funny when you look at where they are from. Some of 
these Asians came from White suburbia, joined a White fra- 
ternity in college and were considered acceptable. They never 
called themselves Asians. If anything, they called themselves 
"Oriental," which in our context is like saying I'm a "Negro/' 
Some of these researchers get fronted off to our community, 
but they may have absolutely no understanding of who we 
are and what we are. They have a different basis in reality. 
Their skin color may be Asian, but they're something else. 
Often, I would much rather have people like you coming into 
my community and working with me than those "Orientals/' 
because they are the most dangerous. I can deal with you. 
But it is hard to deal with them. 

(3) Here is a third way. Some university type, sitting in some 
office on some campus somewhere, gets funded by some 
research institute for a design he dreamed up out of his own 
head, and he does his study at the university with a college 
student sample. Half those Asians who are sampled are from 
overseas. They are not representative of our population, and 
unfortunately, these academicians publish. The saddest thing 
is that what they publish becomes part of the foundation of 
science that I must use if I want to start doing research — . 
These research findings may be fraught with errors and 



434 



biases. Much of our research legacy in the 1950s, 1960s, and 
1970s has been personality and cross-cultural research done 
by White researchers, often predicated on stereotypical 
notions that Asians are passive or self-abasing. There are 
many studies of this kind, and the worst thing about it is 
that these are some of the same people that sit on the Initial 
Review Groups (IRGs). So if and when I want to submit a 
grant application, it goes to that person. 

The bottom line is resources to conduct research, and that 
means money. Who does it go to? You know, it's very interesting 
listening to Dr. Langton speak about where those 27 grant appli- 
cations came from that were submitted in response to the RFP. 
Almost half those grants were from minority Principal Investiga- 
tors, and that is good to hear. Ten out of those 27 grants were 
submitted from community organizations. Now, if we sent those 
27 grants that you received for that RFP to your regular IRG, 
do you know where those grants would go? To academicians 
and Whites. But if you set up a special IRG, then maybe we 
might get somewhere. 

This is not to say a special IRG would not understand good 
science. I think some points have been made about that earlier, 
because we can have good science as well. The difference is that 
our priority may not be tenure. This has been mentioned before; 
it might not be tenure, it might not be money, it might not be 
claim to fame. I'm not saying those things wouldn't be nice; I 
would love to have those things, too. 

We are interested in good science, but we have another prior- 
ity. There is another priority operating here, and that is the fact 
that there is a genuine problem in our cornmunities where we 
live, and these problems are serious. They're hot, and we saw 
it happen in Los Angeles. 

Sometimes I have a hard time going to sleep at night because 
I see many problems in my community. We all see kids dying, 
shooting at each other, drinking and using other drugs. It's a 
struggle to continue to maintain the programs that we have 
because, as Suzie said yesterday, shrinking dollars mean shrink- 
ing resources. You know, we are not even doing stopgap in our 



435 



communities, and when a researcher comes in and says I have 
a bag of money and I want to do this, I get angry because that 
is what we need just to be able to survive. 

But we also need information. We need to know, so it's 
important for us to have research. We want information. But 
you know what is more important? It is more important for 
you to have the information, so when you talk about the Asian 
community, it's much, much more than just a model minority 
to you. We have to convince you that we have a problem. How 
do we do that? Well, it's back to research. 

We want research because we know that knowledge is power 

and it's also a political tool. Knowledge and fact can be defined 

by whoever holds the research hand. We don't have to go very 

far to know that. Research has been used as a political issue for 

jj many, many years. 

NIAAA moving over to NIH raises concerns regarding 
research rigor and worrying about the social science research 
agenda. However, NIH also had their recent series of problems, 
particularly with Dr. Gallo being accused of unfairly making 
the claim to discovering HIV, but then being exonerated. That 
reminds me of four policemen who just got exonerated in Simi 
Valley very recently, and the thing that strikes me is what if 
Gallo was African American? Do you think he would have gotten 
exonerated? He would be tarred and feathered. 

Research is knowledge, knowledge is power, and power is 
money. Money is resources for our communities that we need 
because it may mean the difference between life and death. 

NIAAA has spent much money on "flushing" because the 
model minority myth is that Asians do not have alcohol prob- 
lems. I would like to ask two questions, one to some of the 
researchers around this table and one to NIAAA, and then I'll 
conclude. 

There are White researchers here, and you probably are the 
cream of the crop, the most sensitive. Some of you do credible 
and excellent work with minority communities. Dr. Beauvais' 
work is very interesting to some of my students who would like 
to incorporate some of his ideas in their dissertations and bring 
them to the Asian community. 



436 



The question is, because you are the best, can you still listen 
and continue a dialogue? If you cannot do it, then can you 
imagine what is happening with all those people out there who 
are doing research in ethnic communities? They do not have the 
same sensitivities that you may have. But you are supposed 
to be the most sensitive, the most enlightened, and you have 
been there. 

No one is asking you to leave the community. No one is 
saying hey, get out of the Native American community. No one 
is asking you to get out of the African American community. 
No one has said that yet, and I think no one will. But it is hard 
to listen sometimes because after you put your best effort into 
it, you put your best work into it, you still feel, hey, I don't get 
any thanks for it. But this is part of that process. 

If you are defensive, it means you are listening. And if you 
are listening, that means you are reacting and you are reacting 
emotionally. According to prevention research, you can change, 
because that is what it takes. Listening is one crucial aspect. 
Emotional reactivity is another. We need both, and then you can 
move forward as long as we continue the dialogue. When you 
are defensive you are listening, you are reacting; you do not 
quite understand yet, but you are moving toward that under- 
standing as long as we can continue the dialogue. 

If you're bored, that means you're not even listening. That 
means on the continuum you are here — , but you are not there 
yet. We need to reach you. That is our prevention research. We 
need to reach you if you are bored and indifferent, because you 
are writing us off and you are saying these are a bunch of radical 
types, they do not make any sense and they are nobodies anyway. 
But we need a way to reach you because we want you to work 
with us as well. We want everyone to work with us. 

Some people are defensive; some people are understanding, 
and they are beginning to question. They are saying yes, there 
are some points there, I want to talk to you. That is perfect. That 
is what we want. Talk to us. Let's have dialogue. 

And there are some here who really understand already. You 
have been through this. You can nod your head, oh yes, sure, 
of course, because you have been confronted and you have really 



437 



thought about it and you have had a lot of interaction; or maybe 
it is because you are a woman or maybe it is because you are a 
lesbian or maybe it is because you are Jewish or you are Irish, 
but there is some empathy there because you have seen it within 
your own cultural frame. You understand that process and what 
we're telling you is familiar. 

Now it's hard for you to hear this, I realize that, and some- 
times it is very frustrating. What I just want to say is that I am 
frustrated too, because I have been saying this for a long time. 
My frustration is that we live a reality of day-to-day racism. We 
get hit by this every day. 

So let me move to NIAAA, with my biggest question. What 
are you going to do about this? I am very glad to hear about 
the fact that you are rewriting the RFA. I have no problems with 
NIAAA. Where it has to end is in policy. Policy that will reach 
the IRGs, staffing, advisory committees, and administrative staff. 

The real challenge for NIAAA are the three goals we stated 
yesterday. We want to achieve a better understanding of how 
to do intervention and pre-intervention research in ethnic /racial 
communities. We want to better understand how ethnic /racial 
communities are unique resources for effecting certain types of 
social and behavioral change. We want to understand the process 
of information transfer with respect to proven and promising 
prevention research strategies. 

The answer to that is how well you take on issues that I and 
others have raised here in the past two days. That will answer 
whether or not NIAAA will achieve these goals. 



438 



Part V 

Framing the Research 

Agenda 



21 

Alcohol Prevention Research 

in Ethnic/Racial 

Communities: Framing the 

Research Agenda 



Jan M. Howard 



Introduction 

The ultimate goal of the research task here is a constellation of 
four objectives: (1) to better understand how to facilitate and 
energize scientifically based intervention and preintervention 
research on alcohol-related problems in ethnic /racial communi- 
ties, (2) to learn more about the process of technology transfer to 
and from ethnic /racial communities of ' 'proven" and promising 
prevention strategies, (3) to better understand ethnic /racial com- 
munities as unique resources for effecting certain types of social 
and behavioral change, and (4) to further develop, opera tionalize, 
and examine the concept of "participatory research" as it applies 
to ethnic /racial communities. 

In this context, the phrase intervention research refers to testing 
strategies believed to have the potential of preventing or reduc- 
ing alcohol-related problems. The emphasis is on the prevention 
of problems rather than their treatment after the fact. However, 
the distinction between prevention and treatment may be 
blurred, since the detection and treatment of problems in their 
incipient or early stages can prevent the later onset of more severe 



441 



problems and reduce the probability of relapse. Pre-intervention 
research is directly relevant to the development of effective preven- 
tive interventions and techniques to measure their impact. Tasks 
include identifying appropriate target groups, risk factors, out- 
come variables, and channels for delivering the intervention, 
as well as selecting (or constructing) and pretesting necessary 
measuring instruments. 

The concept of technology transfer refers to a bidirectional 
process by which strategies that were effective in other settings 
and populations are adopted (or adapted) for use in ethnic/ 
racial communities; and where, reciprocally, strategies perfected 
in ethnic /racial communities are transferred to the community 
at large (e.g., coalitions against alcohol advertising that targets 
specific groups). From a research perspective, the notion of tech- 
nology transfer also encompasses its antithesis — deliberate and 
nondeliberate recalcitrance in adopting the policies and pro- 
grams of other communities. 

The idea of ethnic /racial communities as unique resources for 
change suggests that these communities have their own cohesive- 
ness, needs, vibrancy, flexibility, inflexibility, and sociocultural 
definitions of reality. To the extent that such communities are 
unique, they represent a challenge to the ingenuity of alcohol 
prevention researchers. Even where these communities are mere 
microcosms of the larger society, they are still relevant targets 
for intervention studies, offering opportunities to replicate tests 
of interventions that have proven to be effective elsewhere. 

Participatory research is in some sense an abstraction or reifica- 
tion that is still being operationalized in terms of actual experi- 
ence. As currently defined in the limited literature on the topic, 
participatory research means that members of the target popula- 
tion are full partners with investigators in research planning, 
implementation, evaluation, and dissemination (DeCambra, et 
al., 1992). Advocates of the participatory perspective in ethnic/ 
racial-focused studies assume that it helps to assure validity of 
the findings, cultural sensitivity, and researcher accountability 
(DeCambra, et al., 1992). However, these assumptions should be 
subjected to their own tests of validity in the variety of settings 
in which participatory prevention studies are being conducted. 



442 



Although the concept may be ideologically attractive, in practice 
participatory research may have both negative and positive 
effects on the integrity of the scientific endeavor. 

In framing a research agenda to address the questions of 
interest here, certain distinctions should be drawn between the 
various objectives. The first and fourth objectives (facilitating 
prevention studies and examining the concept of participatory 
research) essentially require research on research, because the 
research process is the central focus of investigation. In the sec- 
ond and third objectives (examining mechanisms of technology 
transfer and understanding ethnic /racial communities as unique 
resources for change), the research process per se is not the 
focus of study; but the research on research perspective may still 
be germane. 

For example, in studying the transfer of prevention techno- 
logies to and from ethnic /racial communities, investigators 
might also be interested in whether and how communication of 
research findings influences the diffusion of prevention strate- 
gies. Stated in question form: To what extent is the diffusion, 
adoption, or rejection of particular preventive interventions 
based on a foundation of scientifically grounded research as 
opposed to other considerations? In studying ethnic /racial com- 
munities as instruments for social change, it may be relevant for 
investigators to consider how members of these communities 
view the pros and cons of prevention research — whether they 
regard such studies as potentially beneficial or detrimental to 
their own indigenous objectives. 

Systematic Phases of Prevention 
Research 

Several federal Institutes that sponsor and engage in health- 
related prevention research (including the National Cancer Insti- 
tute (NCI), the National Heart, Lung, and Blood Institute 
(NHLBI) and the National Institute on Alcohol Abuse and Alco- 
holism (NIAAA)) have developed models that define prevention 
research in terms of a systematic progression of research phases 
that reflect an internal logic (Greenwald and Cullen, 1985; Green- 



443 



wald and Caban, 1986; Greenwald, et al, 1987; National Heart, 
Lung, and Blood Institute, 1987; and Flay, 1986). 2 

This logic presumes that research should move in measured 
steps along a series of relevant continuums: 

• from descriptive hypothesis-generating pilot studies to 
full-fledged methodologically sophisticated hypothesis- 
testing studies 

• from smaller to larger samples of subjects 

• from convenience samples to rigorously defined subject 
populations that permit more precise generalization of 
findings 

• from greater to lesser control of experimental conditions 
(frequently referred to as moving from "efficacy" to "effec- 
tiveness" studies (Flay, 1986)) 

• from more artificial "laboratory" environments to real- 
world geographically defined communities 

• from testing the effects of single prevention strategies (or 
first order interactions) to more complex studies of multi- 
ple strategies integrated into intervention systems 

• from research-driven outcome studies to so-called "dem- 
onstration" projects that evaluate the capacity of various 
types of communities to implement prevention programs 
based on these outcome findings. 

Implicit if not explicit in models of research phases is a pre- 
cautionary interest in possible deleterious consequences of pre- 
ventive interventions. This type of concern is more likely to be 
expressed in test situations that mirror medically oriented clinical 
trials where the proscription to "do no harm" has historical 
precedent. For example, preventive interventions in the cancer 
area frequently involve so-called chemopreventive agents (such 
as beta carotene) or dietary "prescriptions" that may have nega- 
tive side effects. These kinds of interventions tend to be conceptu- 
alized as proxies for drugs. And, taking their cue from the phases 
model of the Food and Drug Administration (Flieger, 1990; 
Young, 1990), the NCI and NHLBI attempt to determine toxicity 
levels early in the testing process. 

However, in areas of prevention research that focus on behav- 
ioral change strategies as their intervention approach, there is a 



444 



tendency to down play negative side effects, in spite of evidence 
showing that certain behavioral technologies may have signifi- 
cant deleterious consequences. For example, results from evalua- 
tions of education programs to prevent youth substance abuse 
suggest that they have the potential to stimulate "alcohol and 
drug experimentation, especially when they are implemented by 
instructors who do not have adequate motivation and training 7 ' 
(Moskowitz, 1989, p. 70). And under some circumstances, young 
adults who are informed of the effects of drinking on BAC levels 
will increase (rather than decrease) their consumption of alco- 
holic beverages (Myers, et al, 1991). 

More important, perhaps, than these "boomerang" effects 
of particular prevention strategies are threats to the scientific 
integrity of the research process itself, threats to the implementa- 
tion of research as well as its validity. Problems can occur along 
the entire sequence of research phases from hypothesis and meth- 
ods development through various forms of data collection and 
utilization. We know these problems exist, but conceptualizing 
them as research foci in their own right is essentially virgin 
territory. Generally speaking, we have neglected to study the 
research process itself, whether or not ethnic /racial communities 
are the targets of the intervention /evaluation efforts. Illustrations 
of problems that merit study from other fields of prevention and 
treatment research are instructive. 

In discussing minority focused health research, DeCambra 
and colleagues (1992) observe that "the community response to 
conventional research may involve either indirect resistance or 
direct sabotage" and that these reactions are "culturally appro- 
priate forms of self-defense, representing an adaptive response 
to a perceived imposition." However, in other types of minority 
communities, sabotage of the research process may simply be a 
perceived form of self-help rather than a deliberate attempt to 
undermine research per se. 

For example, it has been observed (Melton, et al., 1988) that 
some AIDS patients involved in clinical trials of azidothymidine 
(AZT) surreptitiously shared doses of their "therapy" to ensure 
that all participants had some access to the experimental drug 
regardless of their assignment to treatment or control (placebo) 



445 



conditions. Obviously, such violations of protocol compromise 
the methodological integrity of clinical trials and the validity of 
results. Thus, attempts have been made to involve AIDS patients 
and their representatives more fully in the research process 
(Howard and Barofsky, 1992), including the design of clinical 
trial protocols that simultaneously meet the needs of science and 
the AIDS community (Byar, et al., 1990). 

A down side exists for minority and majority communities 
if they isolate themselves from validation of the effectiveness of 
preventive interventions. Choosing to implement an untested or 
poorly tested prevention strategy, or one that has proven to be 
ineffective, can result in financial costs that are not offset by 
beneficial outcomes, even in the absence of actual harm. And 
failure to achieve desired objectives can dissuade policy makers 
from implementing and testing alternative or amended strategies 
that show greater promise of success. However, these problems 
would not necessarily be of concern to investigators unless they 
become involved in the final phases of research sequences, when 
technology transfer occurs and research demonstration projects 
give way to service demonstrations (Howard, 1993). 

Pertinent Review Criteria 

Public and private organizations that support alcohol prevention 
research and demonstration /evaluation projects have the oppor- 
tunity to hold investigators and program implementors account- 
able to the state of the art. Questions such as the following 
deserve consideration and are being considered by scientifically 
astute grant review committees in the prevention area: 

• Does the proposed intervention for testing rest on firm 
theoretical foundations? 

• Is it relevant to the proposed target population? 

• Is there sufficient statistical power to appropriately test 
the intervention, or will the guiding question remain unan- 
swered? 

• Is there convincing evidence that relevant community 
organizations will support the research endeavor? 



446 



• Will they help protect the scientific integrity of the study 
against such sources of bias as self-selection of subjects, 
respondent attrition, and self-serving questionnaires? 

• How generalizable will the results of such a study be? 
These kinds of questions reflect the fact that the success 

of scientifically sophisticated community prevention research 
depends on an in-depth understanding of the target community 
by the investigators involved and a genuine commitment of 
support and participation from the community itself. Commu- 
nity action groups are unlikely to obtain research funding from 
the National Institute on Alcohol Abuse and Alcoholism 
(NIAAA) unless the principal investigators have established 
track records in conducting similar studies. Review committees 
are not disposed to sell science short. Nor are they disposed to 
minimize the importance of community collaboration. 

Basic Issues for Research 

Beyond these issues of interest to scientifically oriented review 
groups is another set of fundamental questions seldom addressed 
by designers or reviewers of alcohol studies in ethnic /racial 
communities. These questions are concerned with overarching 
social, psychological, and political realities that have important 
implications for the content and conduct of research as well as 
technology transfer. At the moment, credible information bearing 
on these issues is sometimes so scant as to be virtually nonexis- 
tent. Studies in related areas (such as case histories of the civil 
rights movement) may be instructive, but they are more likely to 
be useful as sources of hypotheses than sources of extrapolations. 
The discussion to follow briefly examines some questions 
and themes that merit extensive exploration at the interface of 
alcohol prevention research and social action in ethnic /racial 
communities. The proposed list of topics is not meant to be 
exhaustive, but it provides a menu of understudied or ignored 
issues relevant to the constellation of research objectives set 
forth above. 

Indigenous Social Movements 

Much of the impetus for preventive interventions in the alcohol 
area comes from formal and informal community-based organi- 



447 



zations, of which some (e.g., Mothers Against Drunk Driving) 
have achieved national visibility and influence (Hingson, 1993). 
Ethnic /racial communities have developed their own indige- 
nous social movements and strategies to reduce alcohol-related 
problems. One example is provided by recent extensive cam- 
paigns against billboard advertising of alcoholic beverages in 
areas heavily populated by ethnic /racial groups (Wallack, et al., 
1993; Girard, 1988). Several aspects of this movement merit study: 

• motivation of participants 

• operationalization of the concept of empowerment 

• perceptions of deleterious consequences of billboard 
advertising by participants and nonparticipants in the 
movement 

• outcomes of the social campaign with respect to the adver- 
!j tisements, drinking behaviors of persons in those commu- 
nities, and other indices of social change. 

Protective Social Institutions And 
Processes 

Studies show that African American youth have lower rates of 
alcohol use and abuse than Whites or Hispanics, across various 
school grades and indices of use (Johnston, et al., 1992). Data 
for Hispanic youth suggest a close resemblance to data for 
Whites, with no consistent tendency for either group to show 
the higher or lower rate of use or abuse (Johnston, et al., 1992), 
except that over time Hispanic youth have consistently reported 
lower rates of binge drinking than Whites (Johnston, et al., 1992,). 
In later life, however, African Americans (especially males) are 
at excessively high risk for acute and chronic alcohol-related 
illnesses such as cirrhosis and cancer of the esophagus (National 
Institute on Alcohol Abuse and Alcoholism, 1990, p. 33). And 
data for Hispanics suggest relatively high rates of alcohol-related 
problems (Caetano, 1986) including drunk driving (as measured 
by arrests for driving under the influence) (Ross, et al., 1991) and 
mortality from motor vehicle accidents (Sutocky, et al., 1993). 
Hispanics may also have a relatively high death rate from cirrho- 
sis (See Caetano in this volume; Caetano, 1986). 



448 




Whatever the age group being considered, Asian Americans 
have historically shown less frequent use and abuse of alcohol 
than non- Asians (National Institute on Alcohol Abuse and Alco- 
holism, 1990; Kim, et al., 1992). However, the literature suggests 
that the drinking behaviors of subgroups of Asians may be chan- 
ging in response to the growing numbers and heterogeneity of 
Asian immigrants and their progressive assimilation into Ameri- 
can value systems (National Institute on Alcohol Abuse and 
Alcoholism, 1991; Kim, et al., 1992). 

Studies of Indian youth on reservations show a consistent 
tendency over time for them to use alcohol more heavily than 
non-Indian youth, as indicated by frequency of drunkenness and 
blackouts (Oetting and Beauvais, 1989). Moreover, adult Indians 
in the United States show high rates of cirrhosis, alcohol-related 
trauma, and fetal alcohol syndrome (National Institute on Alco- 
hol Abuse and Alcoholism, 1990). Yet, there is clearly great diver- 
sity in drinking behavior across tribal groups and within a given 
tribe (National Institute on Alcohol Abuse and Alcoholism, 1990; 
Heath, 1989). Some tribes are mostly abstinent while others show 
high levels of alcohol use and abuse, suggesting great variability 
in factors that precipitate or protect against hazardous drinking. 

Research on alcohol problems and prevention strategies 
among the population at large tends to emphasize risk factors 
and their control rather than protective mechanisms. This narrow 
perspective constrains opportunities for culturally relevant pre- 
vention research. Protective institutions and processes (such as 
family and religious practices) could be conceptualized as natu- 
rally occurring preventive strategies, which can lose their 
potency under certain conditions (such as maturation and 
changes in living environments). 

For investigators who conduct prevention research in ethnic/ 
racial communities, recognition of the potential importance of 
naturally occurring protective processes may be theoretically 
and pragmatically helpful. It could facilitate the identification 
of endemic (culturally entrenched) preventive behaviors that 
deserve outcome evaluation in their own right and as intervening 
catalysts for ensuring the success of investigator-initiated inter- 
ventions. Moreover, researchers who view ethnic /racial commu- 



nities as dynamic systems involving protective as well as hazard- 
ous processes may be better received by target populations who 
are "tired" of being negatively stereotyped. 

Sociocultural Institutions As Agents Of 
Change 

Alcohol prevention researchers have identified ethnic /racial 
institutions that have the potential of serving as facilitators and 
expediters of social change. For example, the church, family, 
and trade unions have been mentioned as possible vehicles for 
preventive interventions in African American or Hispanic com- 
munities (Caetano, 1986; Herd, 1986; Corbett, et al., 1991; and 
Ames and Mora, 1988); and the tribal council has been identified 
as a critical institution for effecting change in American Indian 
communities, particularly where different environmental con- 
trols over the availability of alcohol are a proposed intervention 
(e.g., becoming legally "wet" with enforced constraints) (May, 
1986; May 1989). 

A few alcohol researchers are engaged in pre-intervention 
research in ethnic /racial communities that attempts to under- 
stand the role of the family, church, and other indigenous com- 
munity organizations in preventing or fostering alcohol-related 
problems. In some situations, these institutions play multiple 
and conflicting roles. For example, family members may attempt 
to discourage deleterious drinking while simultaneously serving 
as prestigious models for risky behavior. Similarly, churches may 
try to discourage problem drinking while concurrently sponsor- 
ing festivities and social events that can encourage hazardous 
drinking. 3 And indigenous organizations that work to reduce 
social problems in ethnic /racial communities may face conflicts 
of interest if they accept financial donations from segments of 
the alcohol industry (Maxwell and Jacobson, 1989). 

Pre-intervention research may be less threatening and visible 
to a community than research that tests specific prevention or 
behavioral change strategies. However, it may be difficult to 
convince authorities in focal institutions that studies of their 
organizations have relevance to the ultimate task at hand. If 



450 



these institutions propose themselves for study, entry should be 
easier than if the impetus for research comes from the outside. It 
should also be recognized that methodologies for organizational 
analysis frequently involve in-depth observations of policy-mak- 
ing processes and in-depth interviews of decision makers. 
Because these techniques can appear invasive and intrusive (mir- 
roring in some respects investigative reporting), researchers must 
proceed cautiously, regardless of their own ethnic backgrounds. 



Pertinence Of Findings From Studies Of 
"Majority" Populations 

The concepts of "cultural sensitivity" and "cultural competence" 
have alerted us to the need for caution in applying findings from 
studies of Caucasian and Anglo populations to other groups in 
American society. However, it should not be assumed that eth- 
nic/racial communities will respond differently to preventive 
interventions than majority groups respond. Cultural sensitivity 
simply demands that "proven" strategies be re-tested or reevalu- 
ated before their generalizability can be assumed. 

Among the preventive interventions that have shown effec- 
tiveness in reducing alcohol-related problems in the population 
at large (National Institute on Alcohol Abuse and Alcoholism, 
1990; National Institute on Alcohol Abuse and Alcoholism, in 
press; and Hansen, 1993), a number of strategies are ready for 
testing (and perhaps adaptation) in ethnic /racial communities. 
These interventions include: 

• controls on drunk driving such as random road blocks, 
license revocation, enhanced law enforcement, and 
server training 

• constraints on the availability of alcohol 

• increases in the price of alcoholic beverages from taxes 
and other mechanisms 

• changes in group norms and enhanced peer resistance 
skills through school-based programs 

• techniques of persuasion that combine the mass media and 
more personal forms of communication. 



One nonintrusive research approach is to measure interven- 
tion effects on ethnic /racial groups through secondary analyses 
of existing data sets that contain such demographic identifiers 
as race, ethnicity, and socioeconomic status. The best studies for 
the task here might be those that oversampled ethnic /racial 
populations. Sometimes, ecological (aggregate) data might serve 
as a proxy for individual identifiers, but conclusions drawn from 
ecological comparisons can be misleading or fallacious. 

The alternative to secondary analyses is to start fresh and 
test in ethnic /racial communities interventions that have shown 
promise in populations that are largely Caucasian or Anglo. This 
approach obviously requires access to such communities and 
appropriate support. Access need not necessarily depend on the 
receptivity of ethnic /racial-group "gatekeepers." For example, 
segments of the hospitality industry that serve alcoholic bever- 
ages to persons of color may actually be controlled and managed 
by Whites. Similarly, school districts that serve children who 
are primarily nonwhite may be controlled by persons who are 
primarily White; and law enforcement in ethnic /racial communi- 
ties may be formally beyond the control of those communities. 
In most research situations, however, the ability to conduct an 
effective study ultimately depends on the cooperation of the 
subjects involved (whether they are patrons, pupils, drivers, 
employees, or telephone respondents). 

As indicated above, promising prevention strategies may 
emanate from minority rather than majority communities and be 
reported to the public at large through the mass media. Examples 
include the campaigns against alcohol billboard advertising in 
African American and Hispanic communities (Wallack, et al., 
1993), efforts to constrain rebuilding of alcohol outlets in South 
Central Los Angeles after the fires (Sonenshein, 1993), and the 
forthright attempt of the Alkali Lake Indian Band to reduce 
their alcohol problems (Alkali Lake Indian Band, 1985). These 
indigenous mobilizations have important prevention implica- 
tions for majority as well as ethnic /racial communities. They 
should, therefore, be studied in their own right and in terms of 
their potential for and instances of technology transfer. 



452 



Validity Of Findings 

Because alcohol use and abuse have moral and legal implications, 
answers to questions concerning alcohol-related behaviors are 
vulnerable to the influence of these moral /legal considerations. 
Self reports, which form the major source of epidemiologic data, 
are particularly susceptible to ' 'social acceptability 7 ' distortions. 
But sensitivity to issues of privacy can distort other forms of 
data as well. For example, physicians may refrain from entering 
into patients' charts evidence of alcohol abuse; and these protec- 
tive actions may be influenced by the race, ethnicity, and socio- 
economic status of the patients involved. 

Moreover, people who have been victimized by legal systems 
may be reluctant to voluntarily provide blood, urine, or breath 
samples for confirmatory analysis (Howard and Barofsky, 1992). 
And they may pressure administrative and legislative bodies 
against collecting data that allows linkages between stigmatized 
behaviors (such as alcohol abuse) and stigmatized demographic 
characteristics (Howard, et al., 1989). 4 

One proposed technique to increase the validity of self reports 
is to use interviewers indigenous to the target ethnic community. 
Experts have suggested to the author that the ethnic status of 
interviewers is most likely to influence ethnic /racial responses 
to politically sensitive questions. It remains to be determined 
whether questions about alcohol abuse and its prevention fall 
into the "political" category. 

Clearly, this whole area of validity with respect to ethnic/ 
racial-focused research merits investigation, because it bears on 
the credibility of conclusions drawn from such research. Related 
issues concern the representativeness of study populations. For 
example, it has been argued that ethnic /racial respondents who 
complete high school or who have telephones may be a more 
select subgroup of the population at risk for alcohol problems (or 
protected from them) than their Caucasian /Anglo counterparts. 
These types of concerns have prompted some investigators to 
focus on the identification of school dropouts and techniques of 
ensuring adequate follow-up. And grant review committees have 
been willing to approve home interviews as a means of expand- 



ing samples of ethnic /racial subjects to include persons beyond 
the reach of telephones. 

Perceptions Of Problems And Solutions 

Ethnic /racial communities may have a special stake in the results 
of epidemiologic and intervention studies in the alcohol area- 
because of problem prevalence, ethnic pride, fears of disempow- 
erment, and the quest for self-determination and improvement. 
A wealth of evidence suggests that ethnic /racial groups are con- 
cerned about alcohol problems in their communities. Thus, for 
example, most American Indian tribes have elected to proscribe 
the sale of alcohol within reservation boundaries (May, 1989). 

Yet, we have a paucity of systematic data regarding such 
issues as community definitions of alcohol problems, awareness 
of their prevalence, perceptions of their relative importance vis- 
a-vis other community problems and priorities, perceptions of 
problem etiology, preferred approaches to the reduction of alco- 
hol problems, and how ethnic /racial populations and subpopu- 
lations interpret and "receive" strategies proven to be effective 
elsewhere. 

Ethnographic data from an ongoing study of Hispanics sug- 
gest that interest in self-rule can take precedence over environ- 
mental solutions to alcohol problems when these solutions are 
imposed or implemented by outsiders. There are also reasons 
to believe that findings that suggest genetic causes of alcohol 
problems among ethnic /racial groups may be particularly sus- 
pect, necessitating investigator adherence to higher-standards of 
scientific proof and replication than are usually required. 

Conclusion 

The central integrating theme in this paper is the issue of participa- 
tory research; the idea deserves research attention by itself. 
Although the focus of this monograph is ethnic /racial communi- 
ties, participatory research is germane to any community-based 
intervention study in which the success of the research endeavor 
depends on participation of community residents. Such partici- 
pation may involve shared decision-making with respect to the 



454 



interventions to be tested, target populations, the experimental 
design, types of questions to be asked, selection criteria for project 
personnel, and management of the project. 

Research on participatory research should focus on the fol- 
lowing types of questions: To what extent is the participation of 
community members necessary to implement and complete the 
research project? Does participation threaten the scientific integ- 
rity of the study? And if so, how can that integrity be protected? 
Given community participation, is the concept of ' 'investigator- 
initiated interventions" a realistic notion? Or are the interven- 
tions actually initiated and shaped by the community? Assuming 
the latter, to what extent is it possible to generalize research 
findings to other communities? Is participatory community 
research more akin to "natural experiments" 5 than to traditional 
research in which the investigator controls the intervention to 
be tested? Do interventions implemented through participatory 
research have greater staying power after the study is completed 
than interventions prescribed solely by the investigators? 

With specific reference to ethnic /racial communities, other 
questions of interest concern the degree to which cultural sensi- 
tivity and competence are necessary conditions for the success 
of the research endeavor and how these concepts are operationa- 
lized in practice. Additionally important are questions concern- 
ing the representativeness of ethnic /racial participation in com- 
munity research projects. How can researchers ensure that the 
sharing/participatory process involves all relevant subgroups 
of the community and that all participants appreciate the pre- 
cepts of science? 

Studies of participatory research are likely to include qualita- 
tive (e.g., ethnographic) and quantitative methodologies to docu- 
ment the process of community participation and nonparticipa- 
tion. Ideally, that process should involve a continuous exchange 
of ideas and a continuous interpretative dialogue between 
researchers and members of the community regarding interven- 
tion approaches, apparent successes and failures, and new 
hypotheses or "gut" feelings that may merit study in their 
own right. 

Succinctly stated, there is a critical need for realistic system- 
atic appraisals of factors that facilitate and factors that impede 



455 



state-of-the-science prevention research in ethnic /racial commu- 
nities. 



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End Notes 

1. The scale used to measure acculturation has been described 
in detail by Caetano. Briefly, the scale was built with twelve 
items assessing daily use and ability to speak, read and write 
English and Spanish; preference for media in English or Span- 



458 



ish; ethniticy of the people respondents interacted with in 
their church, parties, and neighborhood now and when grow- 
ing up, as well as questions about values thought to be charac- 
teristic of the Hispanic way of life. 

2. The phases model developed by NIAAA is still being refined. 

3. Recent awareness by churches of their possible contribution 
to risky drinking has prompted efforts to reduce social activi- 
ties that involve alcohol and the amount of alcohol served. 

4. There are reasons to believe that the physically disabled may 
differ from other stigmatized groups in this regard; that they 
may wish to have their substance abuse problems validated 
through enumeration to attract greater interest in their 
problem. 

5. "Natural experiments" are defined by the author as "studies 
of naturally occurring preventive interventions and pro- 
grams" — i.e., the interventions are outside the control of the 
investigator (Howard, 1993). 



>> U.S. GOVERNMENT PRINTING OFFICE: 1995 396-890 



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c V6tv 



DHHS Publication No. (SMA)95-3042 
Printed 1995